Quiz 28. week 13. 2019

Question 1

Which of the following symptoms does not qualify as target organ damage in suspected hypertensive crisis?

A: Epistaxis

B: Pulmonary edema

C: Myocardial ischemia

D: Hypertensive encephalopathy

The correct answer is A

This weeks Internet Book of Critical Care podcast is about hypertensive emergency.

Myocardial ischemia, Pulmonary edema and Hypertensive encephalopathy (among others) are considered as proof of target organ damage. Epistaxis, proteinuria and chronic renal failure do not.

IBCC chapter & cast: Hypertensive emergencies

Question 2

Your patient presents with a narrow QRS tachycardia of about 160 beats per minute. He is hemodynamically stable and you wonder whether this is atrial flutter or another supraventricular tachycardia. Which of the following alterations to recording your ECG could help you distinguish these rhythms?

A: Place right sided leads

B: Place posterior leads

C: Place Lewis leads

D: Record a 15-lead ECG

The correct answer is C

source: https://thephysiologist.org

Taming the SRU discusses alternative lead placements in its latest post.

Right sided leads can help you diagnose right ventricular infarction, while posterior leads will help diagnose posterior infarction. A 15 lead ECG is a standard 12 lead ECG with the addition of V4R (Right) and V8 and V9 (Posterior). Lewis lead placement is an alternative lead placement which accentuates atrial activity.

Question 3

Your patient with Waldenstroms macroglobulinemia presents to your ED with suspected hyperviscosity syndrome (HVS). Which of the following symptoms is not part of the classic triad of HVS?

A: Mucosal bleeding

B: Visual disturbances

C: Neurological symptoms

D: Poly arthritis

The correct answer is D

REBELems podcast is about oncologic emergencies this week.

The classic triad in HVS consists of mucosal bleeding, visual disturbances, and neurological symptoms or with any end organ failure.

REBEL Core Cast 7.0 – Oncologic Emergencies

Question 4

Source: Twitter, NEJM

This paper was published on the New England website last week. It discusses the benefits of immediate angiography in patient with Return of Spontaneous Circulation (ROSC) without evident ST-Elevation Myocardial Infarction on the ECG. The authors enrolled 552 patients. The primary end point was survival at 90 days.
Secondary end points included (among others) survival at 90 days with good cerebral performance, duration of catecholamine support, occurrence of acute kidney injury and neurologic status at discharge from the intensive care unit.

What did the authors find?

A: There was no statistically significant difference in the primary end point and no statistically significant difference in any of the secondary end points

B: There was no statistically significant difference in the primary end point but a statistically significant difference in in favor of immediate angiography in need for renal-replacement therapy

C: There was a statistically significant difference in the primary endpoint in favor of immediate angiography

The correct answer is A

This article was not yet discussed in the FOAM society, but definitely will be by next week.

This multicentre, prospective randomized trial included 552 patients. No statistically significant difference in the primary end point and no statistically significant difference in any of the secondary end points.

There is always debate about this topic. So far I have been on the side of angiography in these patients, but the evidence sure is starting to point the other way.

Question 5

Which of the following statements on calcium homeostasis is true?

A: Hyperpigmentation is a sign of hypercalcemia

B: Chvostek’s and Trosseau’s signs are rare signs of tetany seen in severe hypocalcemia

C: More than 90% of symptomatic hypercalcemia cases are due to hyperparathyroidism

D: Osborn waves on the ECG suggest critically low levels of calcium

The correct answer is B

Dustin Taliaferro wrote an extensive post about hypo- and hypercalcemia on emDOCs.

Signs of hypocalcemia depend on the level of calcium and vary from muscle cramps to hyperpigmentation and brittle hair. Chvostek’s or Trosseau’s sign are rare signs that can be seen in hypocalcemia.

Osborn waves (not only seen in hypothermia!) are uncommon but suggest high levels of calcium. A more common ECG abnormality is a short QTc time. More than 90% of symptomatic hypercalcemia cases are due to hyperparathyroidism and malignancy.

EM@3AM: Hyper- and HypoCa

Thanks for joining us and hope to see you next week!

The FOAMed Quiz crew: Eefje, Kirsten, Nathalie and Rick

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