Question 1
‘’Very little about the management of atrial fibrillation is an emergency. And yet we in the Emergency Medicine community have embraced it as such’’ (EM NERD). Rory Spiegel discusses a recently published paper about immediate cardioversion versus a delayed approach in new onset stable atrial fibrillation. Which percentage of patients had spontaneous cardioversion within 48 hours?
A: 29%
B: 49%
C: 69%
D: 89%
The correct answer is C, 69%
This paper is another nail in the coffin of rhythm control approach to atrial fibrillation. Sinus rhythm on the ECG recorded at the 4-week visit occurred in 193 of 212 patients (91%) in the delayed-cardioversion group and in 202 of 215 (94%) in the early-cardioversion group (non inferior).The number of patients who experienced repeated bouts of atrial fibrillation over the first 28-days was similar between the two groups, 30% and 29% in the delayed and immediate strategies, respectively.
However interesting, I really would like to know what would happen if they did not try to cardiovert at all.
EM Nerd-The Case of the Irregular Irregularity Continues
Question 2
emDOCS discussed bleeding in early pregnancy this week. Which statement is true about this condition?
A: Bleeding due to a subchorionic haematoma increases the risk of pregnancy loss
B: A low single serum β-HCG level is diagnostic of an ectopic pregnancy
C: With a β-HCG > 1500 it should be possible to visualise a normal intrauterine pregnancy with transabdominal ultrasound
D: Pelvic bleeding in the case of a viable intrauterine pregnancy has a risk of 50 percent on miscarriage
The correct answer is A
Subchorionic haematoma is a common cause of bleeding and does increase the risk on pregnancy loss. No single serum β-HCG level is diagnostic of an ectopic pregnancy. With a β-HCG > 1500 it is possible to visualise a normal intrauterine pregnancy (IUP) with transvaginal ultrasound. Transabdominal ultrasound can be used if the β-HCG is > 6000. Pelvic bleeding in combination with a viable IUP has a risk on subsequent miscarriage of 10-25 percent.
OBCast: Bleeding in Early Pregnancy and Threatened Miscarriage
Question 3
This ECG is pathognomonic for which electrolyte disturbance?
A: Hypercalcemia
B: Hypokalemia
C: Hypomagnesemia
D: Hypocalcemia
The correct answer is D
Steven Smith’s posted about hypocalcemia on his blog.
Hypocalcemia causes QTc prolongation primarily by prolonging the ST segment. The T wave is typically left unchanged and dysrhythmias are uncommon.
Question 4
Chest pain is a complaint commonly seen in the emergency department. Which of the following symptoms seems to be the most predictive of acute myocardial infarction according to this recently published paper?
A: Chest pressure
B: Pain worsened by physical activity
C: Radiation to left arm or shoulder
D: Radiation to right arm or shoulder
The correct answer is D
REBELem discusses this recently published analysis from the TRAPID-AMI study about predictive symptoms of acute myocardial infarction.
Chest pain radiating to the right arm (OR 3.0) is more predictive of AMI than chest pain radiating to the left arm (OR 2.5), chest pressure (OR 1.7) and pain worsened by physical activity (OR 1.7).
TRAPID-AMI: Predictive Symptoms of Acute Myocardial Infarction (AMI)
Question 5
Transfusion of whole blood seems to be making a comeback both pre hospital and in the Emergency Department . Which of the following is not an advantage of fresh whole blood compared to optimally balanced component therapy (fresh frozen plasma, platelets and packed red blood cell on a 1:1:1 ratio)?
A: Fresh whole blood has a higher hematocrit
B: Fresh whole blood is less likely to cause plasma-associated transfusion reactions
C: Fresh whole blood seems to have a better hemostatic effect
D: Fresh whole blood provides the most physiologic fluid replacement
The correct answer is B
Stephanie Bartikoski wrote an excellent overview on whole blood transfusion on emDOCs.
There seem to be countless advantages of transfusing whole blood, but there are some things to consider. It can be logistically very challenging and the risk of hemolytic transfusion reactions is reason for concern.
Whole Blood in Trauma: Ready for Primetime?
This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet
