Quiz 110, April 9th, 2021

Welcome to the 110th FOAMed Quiz.

Source image: www.tamingthersu.com

Question 1

Your 27 year old patient presents with an anterior shoulder dislocation. You are in doubt whether reduction was successful. You use POCUS to assess the position of the humeral head.

On POCUS (posterior view) the humeral head appears to be deep to the glenoid fossa. What does that mean?

A: Reduction was successful

B: Anterior dislocation persists

C: There is a posterior dislocation

The correct answer is B.

Taming The SRU discussed ultrasound in shoulder dislocation this week.

POCUS has a high sensitivity (99.1%) and specificity (99.9%) for shoulder dislocation. A major advantage is the possibility of real-time reduction confirmation during sedation.

Standard approach is to place the probe posterior and transverse. In case of anterior shoulder dislocation, the humeral head projects deep to the glenoid fossa. In posterior dislocation, the humeral head is superficial to the glenoid.

Source image: www.journalfeed.org

Question 2

This recently published case series is about the reverse valsalva manoeuvre in 11 patients. The reversed valsalva manoeuvre does not require assistance (like the modified valsalva manoeuvre) or IV access (adenosine, diltiazem).

The patient starts by exhaling without forcing in sitting position, followed by pinching the nose and closing the mouth, finished by inhaling against the self made resistance for ten seconds.

Which of the following statements is true?

A: SVT was terminated in 10% of patients

B: SVT was terminated in 50% of patients

C: SVT was terminated in 90% of patients

The correct answer is C

Journal feed covered this small observational trial about the reverse valsalva manoeuvre this week.

The reverse valsalva manoeuvre increases vagal tone, decreases sympathetic activity and seems to be a very simple, patient friendly and safe technique which can be performed autonomously by patients at home. SVT was terminated by this manoeuvre in 10/11 (91%) of patients, including 4 patients who already tried the modified valsalva manoeuvre.

Future studies like randomised controlled trials should be performed in order to see what the true efficacy of this method is.

Source image: www.aliem.com

Question 3

An otherwise healthy 55-year-old woman visits your emergency department with an increasingly painful swollen finger. You think she has flexor tenosynovitis (FTS). 

The Kanavel signs show a high sensitivity (91.4% – 97.1%) but a low specificity (51.3% – 69.2%) in detecting FTS.

Which 2 physical examination findings, combined with tenderness along the flexor tendon sheath and fusiform swelling, constitute the Kanavel signs?

A: Finger maintained in passive flexion

B: Finger maintained in passive extension

C: Pain elicited with passive flexion

D: Pain elicited with passive extension

The correct answers are A & D.

ALiEM covered FTS this week.

FTS is an acute inflammation of the synovial space of a flexor tendon most often caused by Staphylococcus aureus (40-75%). Typically, patients cannot fully extend the finger and it is usually red, warm and swollen. Passive extension is painful. Drainage is required because the tendon sheaths are connected to other deep spaces of the hand and thus inflammation can spread quickly.

SplintER Series: Kitty Nibble: A Case of the Sausage Finger

Source image: www.emdocs.net / www.LITFL.com

Question 4

Lewis lead placement of ECG electrodes is done by:
Placing the Right Arm (RA) electrode on the manubrium
Placing the Left Arm (LA) electrode over the 5th intercostal space on the right sternal border
Placing the Left Leg (LL) electrode over the right lower costal margin

In what case might Lewis lead placement help you?

A: Detecting an epsilon wave in Arrhythmogenic Right Ventricular Dysplasia (ARVD)

B: Detecting flutter waves in atrial flutter

C: Detecting PTa depression in pericarditis

D: Increase accuracy of QT-interval

The correct answer is B

EMDocs covered the Lewis ECG last week.

Lewis lead placement is used to detect atrial electrical activity better. It can be useful in observing flutter waves in atrial flutter and detecting P waves in wide complex tachyarrhythmia.

Question 5

Source image: https://hqmeded.com

Necrotizing fasciitis is a life-threatening and limb-threatening condition. Which of the following statements about the clinical presentation and diagnosis of necrotizing fasciitis is true?

A: About 80% of patients present with fever

B: Early skin findings include edema and purple discoloration

C: The sensitivity of ultrasonography for finding gas in the skin is only 30%

D: The Laboratory Risk Indicator for Necrotizing fasciitis (LRINEC) score is an accurate tool to differentiate necrotizing fasciitis from other soft tissue infections

The correct answer is C.

Necrotizing fasciitis was covered in EMCrit’s Internet Book of Critical Care (IBCC) this week.

In patients with necrotizing fasciitis, fever is present in only 25-40% of cases at admission.
Early findings of the skin include edema and erythema (cellulitis like), but severe pain that extends beyond the skin findings is probably the most useful clinical finding.

Imaging studies (POCUS, CT, MRI) can show subcutaneous gas and abnormal fascia (thickening, filled with fluid, fat stranding).

The LRINEC score should not be used. External validation studies showed poor sensitivity and specificity.

Probably the most important thing to remember is that surgical exploration should be performed if necrotizing fasciitis is suspected based on clinical findings. Lab results and imaging studies are not accurate enough to exclude necrotizing fasciitis.

Necrotizing fasciitis

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen