Quiz 31. week 15. 2019

Question 1


The recently published FLORALI-2 trial is about Non-Invasive Ventilation (NIV) vs High-Flow Nasal Cannula (HFNC) as Pre-Oxygenation Prior to Intubation. The goal of this trial was to determine if preoxygenation with NIV is better than preoxygenation using HFNC in reducing risk of severe hypoxemia during intubation. Did the authors find a difference in severe hypoxemia in the two groups (NIV vs HFNC) and if so, which pre-oxygenation strategy has the lowest risk on severe hypoxemia?

A: Less severe hypoxemia occurred in the NIV group and the difference was statistically significant

B: Less severe hypoxemia occurred in the HFNC group and the difference was statistically significant

C: There was no statistically significant difference between the groups

The correct answer is C

REBELem discussed this trial in detail last week.

There was no statistically significant difference between the groups, although the authors were looking for a massive 15% difference. Furthermore NIV could be more efficient than HFNC due to the underlying pathology (not only as a pre-oxygenation strategy, but as therapy), so it is hard to compare the two groups.

FLORALI-2: Non-Invasive Ventilation (NIV) vs High-Flow Nasal Cannula (HFNC) as Pre-Oxygenation Prior to Intubation

Question 2

Brian Gilberti (core EM) talks about measles in his latest podcast. According to this podcast, what should you do if you have a child with a proven measles infection in your ED?

A: Isolation, give vitamin A and provide post-exposure prophylaxis to non-immune persons who have been in contact with the patient

B: Isolation, start antibiotics to treat bacterial superinfections and provide post-exposure prophylaxis

C: Give the patient a face-mask and treat with supportive care only

The correct answer is A

Measles are a hot topic these days due to the recent measles outbreak in New York and lower immunization coverage in multiple developed countries around the world.

Treat your patient in a single bed negative pressure room in airborne isolation. 2 Doses of vitamin A should be given to reduce overall and pneumonia-specific mortality. Don’t forget to provide post-exposure prophylaxis to non-immune persons and remember they might need to be isolated for up to 28 days as well.

Episode 160.0 – Measles

Question 3

This recently published paper is about tissue adhesive versus sutures for simple facial lacerations. What did the authors find?

A: The use of tissue adhesive was associated with a higher risk of wound dehiscence

B: The risk of wound dehiscence was the same for chin lacerations and other facials lacerations

C: The risk of wound dehiscence was not statistically different for chin laceration repaired with tissue adhesive or sutures

The correct answer is C

Don’t Forget The Bubbles mentioned this paper in their most recent Bubble Wrap.

The bottom line of this paper is that chin lacerations have a higher chance on wound dehiscence but it doesn’t make a difference whether sutures or tissue adhesive are used to close the wound.

The 28th Bubble Wrap

Question 4


Which of the following statements is true regarding the interpretation of a CT-scan of the head?

A: Grey / White matter differentiation is usually a late sign of ischemia

B: The cisterns can help you identify elevated intracranial pressure

C: A subdural hematoma is typically lens shaped

D: Intraventricular blood is always traumatic

The correct answer is B

SinaiEM discusses a structured approach to interpreting a CT scan of the brain.

Blood can be either epidural, subdural ( crescent shaped), subarachnoidal (SAH), intraparenchymal (IPH) or intraventricular ( which can also be caused by ventricular rupture of IPH or SAH). Grey/White matter differentiation can be the first sign of ischemia. The cisterns can help you identify elevated intracranial pressure, look for absent or compressed cisterns.

Question 5

Which of the following statements is true about Metformin Induced Lactic Acidosis (MILA)?

A: Metformin is renally cleared

B: Patients with an acute intoxication with Metformin become very ill soon after ingestion

C: Nausea, vomiting, diarrhea, epigastric pain are pretty rare in Metformin Induced Lactic Acidosis (MILA)

D: Dialysis is not useful in treating MILA

The correct answer is A

This weeks Internet Book of Critical Care is all about Metformin toxicity.

Metformin is renally cleared and progressive renal failure (with GFR << 30 ml/min) eventually leads to metformin accumulation and toxicity. Patients with an acute intoxication with Metformin may look fine initially, but deteriorate subsequently. Gastro-intestinal symptoms often predominate like nausea, vomiting, diarrhea, epigastric pain. Dialysis is indicated in severe (pH <7,10) illness of if no improvement.

IBCC chapter & cast: Metformin-induced lactic acidosis, et al.

This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet


 

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2 Replies to “Quiz 31. week 15. 2019”

  1. Is MALA still a real thing or is it that metformin itself does not cause lactic acidosis, that it is actually due to the underlying conditions such as renal failure and diabetes mellitus?

    Maybe an interesting topic for a debate?

    1. Dear Prof dr. Zwets. Thank you for the comment! The underlying mechanism remains uncertain. All there is at this point is a clear association (not causation) between use of metformin and lactic acidosis. Some distinguish MALA (Metformin Associated Lactic Acidosis) and MILA (Metformin Induced Lactic Acidosis). One could argue metformin might aggravate an existing acidosis caused by an underlying condition, but this mechanism isn’t clear either. So for now, MALA and MILA remain controversial as a disease entity.

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