{"id":2086,"date":"2017-12-08T16:21:43","date_gmt":"2017-12-08T21:21:43","guid":{"rendered":"https:\/\/www.roshreview.com\/?p=2086"},"modified":"2017-12-08T16:21:43","modified_gmt":"2017-12-08T21:21:43","slug":"ep-37-tibial-vein-clot-pr-interval-epsilon-wave-commotio-cordis-posterior-vitreous-detachment-fish-poisoning","status":"publish","type":"post","link":"https:\/\/www.roshreview.com\/blog\/ep-37-tibial-vein-clot-pr-interval-epsilon-wave-commotio-cordis-posterior-vitreous-detachment-fish-poisoning\/","title":{"rendered":"Podcast Ep 37: Tibial Vein Clot, PR Interval &amp; More"},"content":{"rendered":"\n<figure class=\"wp-block-audio\"><audio controls src=\"https:\/\/media.blubrry.com\/thereveal\/s\/media.blubrry.com\/roshcast\/s\/content.blubrry.com\/roshcast\/Ep_37_Roshcast_Emergency_Board_Review.mp3\"><\/audio><\/figure>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\"><p>The most difficult thing is the decision to act, the rest is merely tenacity. The fears are paper tigers. You can do anything you decide to do. You can act to change and control your life; and the procedure, the process is its own reward. &nbsp;<\/p><cite>-Amelia Earhart<\/cite><\/blockquote>\n\n\n\n<h6 class=\"wp-block-heading\">Welcome back to Roshcast Episode 37!&nbsp;<span>This week, we\u2019re continuing our collaboration with the <a rel=\"noreferrer noopener\" aria-label=\" (opens in a new tab)\" href=\"http:\/\/emclerkship.com\" target=\"_blank\">EM Clerkship podcast<\/a>. We\u2019ll cover 3 EKG related questions in addition to 3 randomly generated questions. Maybe we\u2019ll even get to a trauma question\u2026&nbsp;<\/span><\/h6>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><span>As a reminder, listen closely for the trauma ring tone during this episode and the next episode. And e-mail us at <a href=\"mailto:roshcast@roshreview.com\">roshcast@roshreview.com<\/a>&nbsp;or tweet us at Roshcast the exact time of the ring tone to win a subscription.&nbsp;With the in-training exam right around the corner, this will certainly help get you ready for February 28th. Let\u2019s get going with a rapid review from a recent <a rel=\"noreferrer noopener\" aria-label=\"post (opens in a new tab)\" href=\"https:\/\/www.roshreview.com\/blog\/rapid-review\/rapid-review-supracondylar-fracture\/\" target=\"_blank\">post<\/a> on the <a rel=\"noreferrer noopener\" aria-label=\" (opens in a new tab)\" href=\"https:\/\/www.roshreview.com\/blog\/\" target=\"_blank\">Rosh Review Blog<\/a>.<\/span><\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"178\" height=\"66\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/RapidReview_50.png\" alt=\"\" class=\"wp-image-1608\" \/><\/figure><\/div>\n\n\n\n<ul class=\"wp-block-list\"><li><span><strong>Supracondylar<\/strong> <strong>fracture<\/strong> is the most common type of <strong>pediatric&nbsp;elbow fracture<\/strong>. Typically caused by <strong>falling<\/strong> on an <strong>outstretched hand<\/strong> &#8212; or a FOOSH.&nbsp;<\/span><\/li><li>In a <strong><em>posterolaterally<\/em> displaced supracondylar humeral fracture<\/strong>,<strong>&nbsp;<\/strong>you should be concerned for <strong>the median nerve<\/strong>. This can be tested by asking the patient to make an <strong>\u201cOK\u201d sign<\/strong> and <strong>checking sensation<\/strong> at the <strong>volar tip<\/strong> of the index finger<\/li><li>For a <strong><i>posteromedially<\/i> displaced supracondylar fracture <\/strong>you should be concerned&nbsp;about t<strong>he radial nerve<\/strong>. Have the patient try to make a <strong>\u201cthumbs up\u201d sign<\/strong>. And <strong>check sensation<\/strong> along the <strong>dorsal web space<\/strong> of the hand.&nbsp;<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><span><b>Now onto this week\u2019s podcast<\/b><\/span><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><span><b>Question 1&nbsp;<\/b><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A previously healthy patient who presents with leg pain is found to have a clot within the tibial vein. Which of the following treatments is most likely indicated?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A. Aspirin for 6 months<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">B. Heparin and warfarin<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">C. Repeat ultrasound in 2\u20135 days<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">D. Warfarin alone<span><br><\/span><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><span><b>Question 2<\/b><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Which of the following is associated with a shortened PR interval?&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A. Brugada syndrome<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">B. Mobitz 2\u00b0 AV Block<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">C. Wellens syndrome<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">D. Wolff-Parkinson-White syndrome<span><br><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep37-Wolff-Parkinson-White.png\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><span><b>Question 3<\/b><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A 29-year-old man presents after a syncopal episode. His ECG reveals an epsilon wave, a small positive deflection buried in the end of the QRS complex. Which of the following tests will likely identify the cause of the patient&#8217;s syncope?<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Cardiac catheterization<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Cardiac MRI<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Electrophysiology study<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Stress testing<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep37-Arrhythmogenic-Right-Ventricular-Dysplasia.jpg\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><span><b>Question 4<\/b><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A 12-year-old boy is brought to the ED after being struck in the chest by a baseball during a baseball game. He collapsed immediately upon impact and has been unresponsive since. Which of the following dysrhythmias is most commonly associated with this condition?<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Asystole<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Supraventricular tachycardia <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Ventricular fibrillation<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Ventricular tachycardia<\/span><span><br><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep37-Commotio-Cordis.jpg\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><span><b>Question 5<\/b><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A 57-year-old man with hypertension presents complaining of a 6-hour history of a \u201cfloater\u201d in the right eye. He states that he has had increasing difficulty reading as the cloudy area blocks his visual field. Additionally, he complains of decreased vision in his right eye. Which of the following represents the appropriate management?<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Administer timolol drops and emergently consult ophthalmology<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Emergent ophthalmology consultation <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Prescribe topical antibiotics and refer to ophthalmology<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Refer patient to ophthalmology for further assessment <br><\/span><br><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep37-Posterior-Vitreous-Detachment.png\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><span><b>Question 6<\/b><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A 27-year-old woman and her 25-year-old sister present with symptoms of facial flushing, headache, abdominal cramping, and diarrhea after eating in a seafood restaurant. They report that the fish they ate had a peppery taste. Which of the following is the most likely cause of their symptoms?<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Anaphylaxis<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Ciguatera<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Scombroid<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">D.<i> Staphalococcus aureus<\/i> food poisoning<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep37-Histamine-Fish-Toxicity.png\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"178\" height=\"66\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/RapidReview_50.png\" alt=\"\" class=\"wp-image-1608\" \/><\/figure><\/div>\n\n\n\n<ul class=\"wp-block-list\"><li><span><strong>Isolated thromboses<\/strong> of the calf veins can be managed by <strong>repeating an ultrasound in 2\u20135 days<\/strong> to determine the need for <strong>anticoagulation<\/strong>.<\/span><\/li><li><strong>Phlegmasia cerulean dolens<\/strong> is caused by <strong>extensive iliofemoral occlusion<\/strong>, which leads to <strong>vascular congestion<\/strong> and <strong>venous ischemia<\/strong> and <strong>a painful blue leg<\/strong>.<\/li><li><strong>Phlegmasia alba dolens<\/strong> is caused by a <strong>massive iliofemoral thrombosis<\/strong> and <strong>spasm<\/strong> and <strong>leads to a white leg<\/strong>.<\/li><li><strong>WPW<\/strong> is a <strong>congenital abnormality<\/strong> characterized by an <strong>abnormal accessory conduction pathway<\/strong> between the atria and the ventricle known as <strong>the bundle of kent.&nbsp;<\/strong>Look out for a <strong>delta wave<\/strong>, <strong>short PR<\/strong>, and <strong>widened QRS interval on EKG.&nbsp;<\/strong>The definitive treatment is <strong>ablation<\/strong>.<\/li><li><strong>Brugada syndrome<\/strong> is a <strong>hereditary condition<\/strong> characterized by a <strong>right bundle branch block-like pattern<\/strong> with <strong>ST elevation<\/strong> in <strong>leads V1 through V3<\/strong>.<\/li><li><strong>Wellens syndrome<\/strong> is caused by <strong>critical stenosis of the proximal LAD.&nbsp;<\/strong>On EKG you will likely see <strong>large inverted T waves<\/strong> or <strong>biphasic T waves<\/strong> in <strong>leads V2 and V3.<\/strong><\/li><li><strong>Epsilon waves<\/strong>, which are <strong>small positive deflections<\/strong> buried in the <strong>terminal QRS complex<\/strong>, are characteristic of <strong>arrhythmogenic right ventricular cardiomyopathy.&nbsp;<\/strong>It is diagnosed by <strong>cardiac MRI.<\/strong><\/li><li><strong>Arrhythmogenic right ventricular cardiomyopathy<\/strong> is treated with <strong>antiarrhythmics<\/strong> and an <strong>implantable cardiac defibrillator<\/strong>.<\/li><li><strong>Commotio cordis<\/strong> occurs when an <strong>object strikes the chest<\/strong> over the heart. It can cause <strong>sudden death.&nbsp;<\/strong>Commotio cordis is <strong>most common<\/strong> in <strong>children 5\u201315 years old<\/strong>, and <strong>ventricular fibrillation<\/strong> is the <strong>most common underlying rhythm<\/strong>.<\/li><li>The<strong> commotio cordis risk window<\/strong> is the <strong>upstroke of the T wave<\/strong> in the <strong>cardiac conduction cycle<\/strong>.<\/li><li><strong>Posterior vitreous detachment<\/strong> can cause <strong>floaters<\/strong>, <strong>decreased vision<\/strong>, and <strong>cloudiness.&nbsp;<\/strong>Acute changes warrant emergent <strong>ophthalmology consultation<\/strong>.<\/li><li><strong>Scombroid poisoning<\/strong> presents with <strong>facial flushing<\/strong>, <strong>headache<\/strong>, <strong>abdominal cramping and diarrhea<\/strong>, <strong>palpitations<\/strong>, and <strong>rashes<\/strong>.<strong>&nbsp;<\/strong>Onset of symptoms can be anywhere from <strong>10 minutes to 24 hours.&nbsp;<\/strong>Treatment is supportive with <strong>H1 and H2 blockers<\/strong>.<\/li><li><strong>Ciguatera toxicity<\/strong> is associated with <strong>muscle weakness<\/strong>, <strong>paresthesias<\/strong>, <strong>vomiting<\/strong>, <strong>diarrhea<\/strong>, and <strong>reversal of hot-cold sensation.<\/strong><\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><span>That wraps up Roshcast Episode 37.&nbsp;Before we officially sign off for this week, we wanted to solicit your help for an upcoming episode. Very soon, we are bringing Adam Rosh, who is the founder of Rosh Review, onto the podcast to discuss everything from study tactics to his favorite pre-test meal. We have a couple of our own questions lined up, but we want to know what questions you have. Send us any questions for Adam to <a href=\"mailto:jeff@roshreview.com\">jeff@roshreview.com<\/a> and we\u2019ll try to squeeze them all in. That\u2019s it for this week. Don\u2019t forget to follow us on Twitter&nbsp;<a href=\"https:\/\/twitter.com\/roshcast?lang=en\">@Roshcast<\/a> and <a href=\"https:\/\/twitter.com\/roshreview?lang=en\">@RoshReview.&nbsp;<\/a>And you can always email us at <a href=\"mailto:roshcast@roshreview.com\">roshcast@roshreview.com<\/a> with any feedback, corrections or suggestions.&nbsp;You can also help us pick questions by identifying ones you would like us to review. Write \u201cRoshCast\u201d in the submit feedback box as you go through the question bank. &nbsp;Lastly, if you have a minute, make sure to rate us and leave comments on&nbsp;<a rel=\"noreferrer noopener\" aria-label=\" (opens in a new tab)\" href=\"https:\/\/itunes.apple.com\/us\/podcast\/roshcast\/id1156487141?mt=2\" target=\"_blank\">iTunes<\/a>&nbsp;to help spread the word about RoshCast. We\u2019ll be back soon with more high-quality review.<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Until next time,<br>Jeff and Nachi<\/p>\n","protected":false},"excerpt":{"rendered":"<p>The most difficult thing is the decision to act, the rest is merely tenacity. The fears are paper tigers. You can do anything you decide to do. You can act to change and control your life; and the procedure, the process is its own reward. &nbsp; -Amelia Earhart Welcome back to Roshcast Episode 37!&nbsp;This week, <a href=\"https:\/\/www.roshreview.com\/blog\/ep-37-tibial-vein-clot-pr-interval-epsilon-wave-commotio-cordis-posterior-vitreous-detachment-fish-poisoning\/\">read more&#8230;<\/a><\/p>\n","protected":false},"author":11,"featured_media":2185,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"inline_featured_image":false,"footnotes":""},"categories":[2025,1999],"tags":[2038,2052,2053,2159,2167,2187,2247,2303,2306,2327,2329,2388,2394,2418,2419,2427,2460,2486,2494,2506,2530,2610,2628,2633,2670,2743,2757,2789,2864,2905,2938,2950,3005,3075,3160,3195,3202,3232,3255,3303,3304,3350,3351,3352,3424,3440,3452,3464,3476,3512,3533,3544,3551,3571,3605,3633,3641,3643,3712,3738,3740,3743,3766,3767,3775,3779,3783],"coauthors":[],"class_list":["post-2086","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-emergency-medicine","category-podcast","tag-abdominal-cramping","tag-ablation","tag-abnormal-accessory-conduction-pathway","tag-anti-arrhythmics","tag-anticoagulation","tag-arrhythmogenic-right-ventricular-cardiomyopathy","tag-biphasic-t-waves","tag-brugada-syndrome","tag-bundle-of-kent","tag-cardiac-conduction-cycle","tag-cardiac-mri","tag-ciguatera-toxicity","tag-cloudiness","tag-commotio-cordis","tag-commotio-cordis-risk-window","tag-congenital-abnormality","tag-critical-stenosis-of-the-proximal-lad","tag-decreased-vision","tag-delta-wave","tag-diarrhea","tag-dorsal-web-space","tag-epsilon-waves","tag-extensive-iliofemoral-occlusion","tag-facial-flushing","tag-floaters","tag-h1-and-h2-blockers","tag-headaches","tag-hereditary-condition","tag-implantable-cardiac-defibrillator","tag-isolated-thromboses","tag-large-inverted-t-waves","tag-leads-v1-through-v3","tag-massive-iliofemoral-thrombosis","tag-muscle-weakness","tag-ophtha-lmology-consultation","tag-painful-blue-leg","tag-palpitations","tag-paresthesias","tag-pediatric-elbow-fracture","tag-phlegmasia-alba-dolens","tag-phlegmasia-cerulean-dolens","tag-posterior-vitreous-detachment","tag-posterolaterally-displaced-supracondylar-humeral-fracture","tag-posteromedially-displaced-supracondylar-fracture","tag-qrs-interval-on-ekg","tag-rashes","tag-repeating-an-ultrasound-in-2-5-days","tag-reversal-of-hot-cold-sensation","tag-right-bundle-branch-block-like-pattern","tag-scombroid-poisoning","tag-short-pr","tag-small-positive-deflections","tag-spasm","tag-st-elevation","tag-supracondylar-fracture","tag-terminal-qrs-complex","tag-the-median-nerve","tag-the-radial-nerve","tag-upstroke-of-the-t-wave","tag-vascular-congestion","tag-venous-ischemia","tag-ventricular-fibrillation","tag-volar-tip","tag-vomiting","tag-wellens-syndrome","tag-white-leg","tag-wpw"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v21.7 (Yoast SEO v26.6) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Podcast Ep 37: Tibial Vein Clot, PR Interval &amp; More | RoshReview.com<\/title>\n<meta name=\"description\" content=\"Welcome to RoshCast (Ep. 37), the first question and answer style emergency medicine podcast. 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