Funtabulously Frivolous Friday Five 362

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF, introducing the Funtabulously Frivolous Friday Five 362.

Question 1

Like most everyone in the medical community, I love watching Dr Glaucomflecken videos (as a boomer I see them on FB, but I assume he’s on ‘the gram’, ‘the tube‘ and X as well). Until moments before writing this question, I had always thought ‘glaucomflecken’ was a neologism! …which it is kinda…

So, what is glaucomflecken?

Reveal the funtabulous answer

GlauComflecken is the pseudonym of Dr Will Flanary one of the the internet’s most famous physician/comedian.

GlauKomflecken refers to small anterior subcapsular grey-white fleck-like opacities secondary to lens epithelial cell necrosis.

Glaukomflecken changes are usually seen after an episode of acute primary angle closure (APAC attack), which refers to an eye with a narrow anterior chamber angle that is acutely closed, resulting in marked increases in intra-ocular pressure.

glaukomflecken
Right eye scattered dots of glaukomflecken were seen at the more nasal side of the lens in the layer of anterior lens capsule, pointed out by the red arrows. Visual Journal of Emergency Medicine. 2023
Reference:

Question 2

Is your paediatric patient at higher risk of serious infection when their febrile illness enters its fifth consecutive day?

Reveal the funtabulous answer

Yes, somewhat.

A common teaching in acute paediatrics is to advise blood tests for children with five or more days of consecutive fever. Certainly 5 days of fever is a key diagnostic criteria for Kawasaki Disease. However, prolonged fevers can be caused by so many things – infective AND non-infective, so what is the increase in risk?

Nijman et al performed an excellent prospective observational study across 12 EDs in Europe between 2017 and 2018, consecutively recruiting 35,705 children <18years presenting with fever. Take home points are:

  • 10% of this cohort had fever ≥5 days.
  • Children with fever ≥5 days do have higher risk of serious bacterial infection (SBI) – 8.4% vs 5.7%.
  • Children with fever ≥5 days had similar levels of acuity at triage, similar rates of acute intervention and ICU admissions.
  • Of the patients deemed to have SBI:
    • LRTIs were more common in children with fever ≥5 days – 54% vs 35%.
    • UTIs were seen commonly in both groups – 35% vs. 42%
  • Of the patients with fever ≥5 days:
    • 1.7% had serious but non-infective causes, such as Kawasaki Disease, other inflammatory conditions, and new diagnosis malignancy.

So, knowing the risk of SBI is higher, but still <10%, I advocate that reviewing a patient with prolonged fever always requires more thought, but does not automatically mean more tests.

Reference:

Question 3

What depressing moniker is assigned to this tree?

Cerbera odollam suicide tree

Reveal the funtabulous answer

The Suicide Tree.

Cerbera odollam is a tree species in the family Apocynaceae commonly known as the suicide tree or pong-pong. Its fruit, known as othalanga, has seeds which contain the potent poison, cerberin that have been used for trials by ordeal, suicide, and poisonings. It is native to south and south east Asia, Pacific Island and Queensland, Australia.

Rotella et al, describe a 19-year-old male who presented to their ED following deliberate ingestion of the seeds from two pong-pong seed kernels four hours prior. The kernels had been purchased online 2 weeks prior in the setting of worsening suicidal ideation.

Within 30 min of ingestion, the patient developed epigastric pain, nausea and vomiting. This was followed by ongoing severe nausea with dry retching, chest tightness and generalised paraesthesia. An ECG demonstrated widespread ‘reverse tick’ ST depression in leads II, III aVF, V2-V6 with ST-elevation in aVR.

ECG demonstrating ‘reverse tick’ ST depression and pong pong seeds
ECG demonstrating ‘reverse tick’ ST depression and pong pong seeds Rotella 2020

References


Question 4

What type of injury am I trying to describe if using the Gustilo (-Anderson) Classification?

Reveal the funtabulous answer

Open fractures

Gustilo and Anderson initially described 1,025 patients from Minnesota with open fractures and refined a system to include Types I, II, III.

A subsequent 1984 publication by Gustilo, Mendoza and Williams further classified Type III fractures in sub-types A, B and C.  However, the most accurate way to grade open fractures is by intra-operative examination

The classification system helps describe prognosis and guide antibiotic choice, especially given gram-positive bacteria are present in 78% of open fractures, while gram-negative bacteria are present in 26% of cases.

  • Type I: wound ≤1 cm, minimal contamination or muscle damage
  • Type II: wound 1-10 cm, moderate soft tissue injury
  • Type IIIA: wound usually >10 cm, high energy, extensive soft-tissue damage, contaminated; adequate tissue for flap coverage; farm injuries are automatically at least Gustillo IIIA
  • Type IIIB: extensive periosteal stripping, wound requires soft tissue coverage (rotational or free flap)  
  • Type IIIC: vascular injury requiring vascular repair, regardless of degree of soft tissue injury
Principles of management of open fractures. AO surgical reference
Principles of management of open fractures. AO surgical reference

The ABCD’s mnemonic is an easy way to remember the Gustilo Anderson Classification: area, blood, comminution, dirt, soft-tissue.

Image reference: The Plastics Fella

References


Question 5

What percentage of (adult) patients presenting to emergency with supraventricular tachycardia (SVT) will have elevated serum troponin levels?

  • A. 46%
  • B. 99%
  • C. 73%
  • D. 58%

Reveal the funtabulous answer

D. 58%

In their meta-analysis of 7 studies (n = 500), Ali et al evaluated the prognostic utility of measuring troponin as part of SVT management within emergency. They found the pooled prevalence of major adverse cardiac events (MACE) in SVT was 6%, but that the prevalence was 11% in the group with troponin rise.  Given the altogether low prevalence in both groups, they concluded that elevated troponin has a low prognostic value in predicting MACE.

Although SVT generally has favourable outcomes, still one quarter of presentations result in an admission, incurring greater costs to the patients and families. Furthermore, ordering a troponin level, regardless of the result, has been shown to be associated with longer ED lengths of stay.

Reference:

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Funtabulously Frivolous Friday Five

Dr Mark Corden BSc, MBBS, FRACP. Paediatric Emergency Physician working in Northern Hospital, Melbourne. Loves medical history and trivia...and assumes everyone around him feels the same...| LinkedIn |

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