Quiz 45, September 27th, 2019

Question 1

Source: emdocs.net

Which of the following statements is true about Point Of Care UltraSound (POCUS) assessment of free intraperitoneal air?

A: POCUS has a higher specificity for intraperitoneal air compared to an upright plain X-ray

B: Movement of reverberation artifacts with peristalsis indicates free intraperitoneal air

C: POCUS has a similar sensitivity for intraperitoneal air compared to CT abdomen

D: An enhanced peritoneal stripe sign (EPSS) is caused by a highlighted interface between gas and soft tissue

The correct answer is D

EMdocs covered POCUS for diagnosis of free intraperitoneal air recently.

The sensitivity and specificity for pneumoperitoneum by POCUS are 92% and 53% respectively. The sensitivity is more or less equal to plain radiography. Movement of reverberation artifacts with peristalsis indicates intraluminal air. An enhanced peritoneal stripe sign (EPSS) is caused by a highlighted interface between gas and soft tissue. Normally (with fluid underneath) the peritoneum will only appear as a thin line.

Question 2

Source: emdocs.net

Which of the following statements is true about achilles tendon ruptures?

A: Ultrasound is useful to diagnose an achilles tendon rupture

B: The Thompson Test has a sensitivity of only 75%

C: Ultrasound can help differentiate between complete and partial ruptures

D: Operative management leads to better outcomes compared to conservative management

The correct answer is C

BrownEM covered achilles tendon ruptures last week.

Imaging is not necessary for diagnosis of achilles tendon ruptures. The Thompson Test has a sensitivity of 96%. Nonoperative vs. operative management management remains controversial. And indeed, ultrasound can help differentiate between complete and partial ruptures.

Question 3

Source: litfl.com

Your patient presents with an episode of AV Nodal Reentry Tachycardia (AVNRT) and you want to start with vagal manoeuvers. You wonder weather lifting her legs in the air after blowing the syringe is helpful at all. Is lifting the legs after blowing the syringe (Modified Valsalva) beneficial compared to just blowing a syringe (standard Valsalva) or does it just look silly according to recent evidence?

A: No, modified Valsalva is less effective compared to standard Valsalva

B: Modified Valsalva is equally effective compared to standard Valsalva

C: Modified Valsalva is more effective compared to standard Valsalva

The correct answer is C

REBELem covered this paper last week.

Yes lifting the legs after Valsalva is definitely beneficial. Conversion to sinus rhythm within 60 seconds after manoeuvre was found to be 16% in the standard Valsalva group versus 46% in the modified Valsalva group.

Standard Valsalva vs Modified Valsalva for Cardioversion of SVT?

Question 4

Your pregnant patient is in her 3th trimester (29 weeks) and she presents to your department feeling generally unwell. Her blood pressure is measured twice at 160/100, 4 hours apart and her urine protein to creatinine ratio is 0.45. Does your patient have preeclampsia?

A: Yes, the diagnostic criteria have been met

B: No she does not have preeclampsia

C: Maybe, but it depends on thrombocyte count and transaminase levels

The correct answer is A

NUEM published a great infographic about preeclampsia.

Diagnostic criteria are:
Blood pressure of ≥ 150 / 90 measured twice at least 4 hours apart or a blood pressure or ≥ 160/110 measured twice at least 15 minutes apart AND and-organ dysfunction. Just have a look at the infographic.

Question 5

Source: pixabay.com

The Mallampati score has become a routine part of airway screening in patients undergoing procedural sedation in the Emergency Department.

What is true about the accuracy and reliability of the Mallampati score?

A: The Mallampati score has a high sensitivity to predict a difficult bag-valve-mask ventilation, but lacks an adequate sensitivity to predict difficult intubation

B: The Mallampati score has a low sensitivity for predicting both a difficult bag-valve-mask ventilation and a difficult intubation. Furthermore, it has a poor inter-rater reliability

C: The Mallampati score has a high accuracy and reliability, but only in trained clinicians

The correct answer is B.

This 2019 paper was covered on journal feed last week.

A recent literature review of the Mallampati score in ED airway management and procedural sedation showed a poor sensitivity in predicting difficult laryngoscopy (53%), difficult intubation (51%), and difficult bag-valve-mask ventilation (17%). The inter-rater reliability is also poor. Furthermore, the Mallampati score is designed to evaluate the patient in sitting position, with a wide opened mouth, a protruding tongue and remaining quiet. This can be challenging in critically ill patients (and children).

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

Reviewed and edited by Rick Thissen

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