Quiz 32. week 16. 2019

Question 1

Last week two papers (ConSEPT and EcLiPSE ) were published comparing levetiracetam and phenytoin as second line agents in the treatment of convulsive status epilepticus in children. What is the main conclusion of both papers?

A: Levetiracetam was superior to Phenytoin in terminating seizure activity

B: Levetiracetam was inferior to Phenytoin in terminating seizure activity

C: Levetiracetam was not superior to Phenytoin in terminating seizure activity

The correct answer is C

This post on first10em is about two superiority trials comparing second line treatment of status epilepticus with levetiracetam and phenytoin (ConSEPT and EcLiPSE). Neither trial supports the hypothesis that levetiracetam performs better than phenytoin. However, there are some methodological issues. For example, there was no blinding and therefore both trial are at high risk of bias.

Levetiracetam versus Phenytoin in Status Epilepticus (ConSEPT and EcLiPSE)

Question 2

A 20 year old patient comes in after a liquid substance has been thrown onto him after a fight at school. He is in severe pain and blistering burns can be seen on both arms and legs. Which of the following statements is true?

A: Acid burns tend to be more severe than alkali burns

B: Hydrofluoric acid burns should be treated the same way as acid and alkali burns

C: Alkali burns lead to liquefactive necrosis

D: Tap water is just as effective as hypertonic solutions to rinse the affected skin

The correct answer is C

Don’t forget the Bubbles is all about the management of chemical attacks this week.

Alkali burns tend to be more severe than acid burns because alkali are lipophilic, therefore dissolve in fat and penetrate through the skin and eye more deeply than acid. Hydrofluoric acid is an exception because it causes deep and extensive burns and should be treated (after rinsing with Hartmann’s) with calciumgluconate gel, calciumgluconate IV, calciumgluconate injected in the wounds.. calcium everywhere. Although tap water is a lot better than doing nothing to rinse the skin, hypertonic solutions are preferred because tap water is hypo-osmolar and can lead to ‘’wash in’’, causing deeper penetration of the acid or alkali.

pHirst Aid – Management of Chemical Attacks in Children

Question 3

Source: www.acep.org/

Which of the following findings is not seen on ultrasound in small bowel obstruction?

A: Dilated Fluid Filled Loops

B: To-and-Fro

C: Keyboard Sign

D: Double Barrel Shotgun Sign

E: Tanga Sign

The correct answer is D

Brown EM’s Ultrasound Case of the Month is about small bowel obstruction.

The Keyboard Sign involved the pilcae circulares seen as ‘’black and white piano keys’’. Dilated Fluid Filled Loops can be seen as well, of course. The To-and-Fro sign is caused by intestinal contents moving backwards and forwards. Bits of free fluid outside the bowel wall are called the Tanga Sign. The Double Barrel Shotgun Sign is seen in a markedly dilated Common Bile Duct which may have the same size as the portal vein.


Question 4

Source: rebelem.com

You find yourself in a tough situation. A 26 year old is rushed in by the prehospital services after a single stab wound to the left chest and loses vitals during your primary survey. You intubate and perform a finger thoracostomy bilaterally without regaining Return of Spontaneous Circulation (ROSC). You decide to proceed to a clamshell thoracotomy. Which of the following statements is true regarding this procedure?

A: For internal defibrillation, start with 10 to 20 Joules

B: The pericardium should only be opened in the case of evident tamponade

C: Always place a foley in a myocardial laceration

D: The hand crank and long bar of the Finochietto retractor are places medially

The correct answer is A

rebelEM wrote about thoracotomy this week.

The pericardium should always be opened. Tamponade can occur with very small pericardial effusions (if accumulated rapidly) and can be very difficult to appreciate, so always open the pericardium. A Foley catheter placed in a myocardial laceration can worsen the laceration, so be careful. Putting a finger in the hole is most likely safer. The hand crank and long bar of the rib spreader should be placed laterally.


Question 5

Source: coreem.net/

Which of the following statements about Ovarian Torsion is true?

A: Ovarian arterial and venous flow on Ultrasound Doppler is always absent in the case of ovarian torsion

B: Left ovary torsion is more common because the left utero-ovarian ligament is longer

C: Pregnancy is not a risk factor

D: The “String of Pearls” Sign on the ultrasound is highly specific for ovarian torsion.

The correct answer is D

Ovarian Torsion is most common in reproductive ages females. It rarely presents with classic symptoms. Risk factors are: an ovary >4cm, pregnancy, patients undergoing IVF, and patients after tubal ligation. Right ovary torsion is more common because the right utero-ovarian ligament is longer and the sigmoid on the left side limits ovarian movement. Pain is the most common symptom. Transabdominal ultrasound should be obtained and if negative, transvaginal ultrasound should be the next step. Do not feel reassured by the presence of arterial and venous flow on Doppler as normal flow can be found in up to 60% of torsion cases

CORE EM: Ovarian Torsion

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


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