Podcast Ep 34: Seizures, Yersinia enterocolitica, & More

Keep your eyes on the stars and your feet on the ground.

-Theodore Roosevelt

Welcome back to Roshcast Episode 34! This week we continue our collaboration with the EM Clerkship podcast, focusing on appendicitis. Don’t forget that we launched another trauma ring tone contest last week, so listen up through episode 38 to win the prize. For this week’s rapid review, we reviewed dysbarism in honor of the Rosh Review Core Content Winner’s presentation. If you haven’t seen Dr. Sanders and Dr. Levin’s fantastic presentation, it’s definitely worth checking out. Let’s get started!

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• A diver with an arterial gas embolism would classically presents within 10 minutes with neurologic symptoms that resolve and then recur.
• Typical symptoms of an arterial gas embolism include unconsciousness, respiratory or cardiac arrest, coma, stupor, confusion, unilateral neurologic changes, visual disturbances, dizziness, or convulsions.
• Decompression sickness presents in a variety of ways. 68% of patients will present with joint pains, 63% will present with numb patches and paresthesias, and 41% will have constitutional symptoms and fatigue. Other less common symptoms include dizziness, weakness, itching, hearing loss, and tinnitus.
• On scene, a diver with either an arterial gas embolism or decompression sickness should be treated with the standard IV fluids, supplemental oxygen, and then be placed on a monitor. Definitive treatment is with hyperbaric oxygen.

Now onto this week’s podcast

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Question 1

Which of the following is the average duration of a typical generalized tonic-clonic seizure?

A. 1–2 minutes

B. 10–15 seconds

C. 30–40 seconds

D. 4–5 minutes

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Question 2

A 23-year-old man presents with abdominal pain, vomiting and two loose, nonbloody stools. Physical examination reveals right lower quadrant tenderness to palpation. A CT is performed showing a normal appendix and some inflammation at the ileocecal junction. What pathogen is commonly implicated in this disorder?

A. Aeromonas species

B. Salmonella enterica

C. Vibrio parahaemolyticus

D. Yersinia enterocolitica

Teaching Image

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Question 3

A 9-month-old girl presents to the ED with signs of progressive dyspnea. The patient’s mother reports URI symptoms that have been present for two weeks. Over the previous 24 hours, the patient has been increasingly fussy, noted to be sweaty with feeds, and has become increasingly dyspneic. Her vital signs are T 38.3°C, HR 180, RR 38, POx 93%, and BP 60/40. On examination, you note rales at the lung bases. Her heart rhythm is irregular with an S3 gallop, and the liver is palpable 3 cm below the costal margin. Which of the following is the most appropriate therapeutic intervention?

A. Dobutamine

B. Immediate endotracheal intubation

C. Normal saline 20 ml/kg bolus

D. Propranolol

E. Transcutaneous pacing

Teaching Image

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Question 4

Which of the following statements is true regarding appendicitis?

A. An appendicolith is identified in the majority of cases of appendicitis

B. Leukocytosis is seen in the majority of cases

C. Perforation is rare in patients younger than 2 years

D. The presence of an appetite makes the diagnosis unlikely

Teaching Image

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Question 5

Which of the following is most characteristic of phimosis?

A. Collection of dilated and tortuous veins surrounding the spermatic cord

B. Inability to retract foreskin over glans

C. Inability to return retracted foreskin over glans

D. Painless cyst filled with sperm

Teaching Image

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Question 6

Which of the following historical features has a high positive likelihood ratio for acute appendicitis?

A. Migration of pain from periumbilical area to the right lower quadrant

B. Obturator sign

C. Presence of pain for more than 48 hours

D. Vomiting before onset of pain

Teaching Image

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• The average duration of a generalized tonic-clonic seizure is 1–2 minutes.
• Status epilepticus is defined as any seizure lasting greater than 5 minutes or 2 discrete seizures without a recovery to consciousness.
• For the treatment of status epilepticus, benzodiazepines are the first-line agents. Second-line agents include phenytoin, fosphenytoin, valproic acid, phenobarbital, and levetiracetam. Pentobarbital and propofol are third-line agents.
• Yersinia enterocolitica can cause ileocecitis which can mimic appendicitis. Other symptoms include colicky abdominal pain, fever, nausea, vomiting, and diarrhea. Treatment is supportive.
• Pediatric heart failure is treated with dobutamine if hypotensive or with milrinone if normotensive or hypertensive.
• Common causes for myocarditis include viruses, bacteria, parasites, cardiotoxins, systemic disorders, radiation, and hypersensitivity.
• A leukocytosis is seen in up to 70% of patients with appendicitis.
• Appendicoliths are rarely identified, they are only seen 10% of the time radiographically.
• 33% of patients diagnosed with appendicitis do NOT report anorexia.
• Phimosis is the inability to retract the foreskin over the glans.
• Paraphimosis is the inability to return the retracted foreskin over the glans.
• Varicocele is a collection of dilated and tortuous veins surrounding the spermatic cord. They usually cause no symptoms.
• There is a high positive likelihood ratio for acute appendicitis with migration of pain from the periumbilical area to the right lower quadrant.
• Obturator sign is the elicitation of pain with flexion and internal rotation of the right hip which signifies a pelvic location of the appendix.
• Rosving sign is palpation of the left lower quadrant causing referred pain to the right lower quadrant.

That wraps up Episode 34. We will be at ACEP next week and hope to meet many of you there. Definitely swing by the Rosh Review booth (1442) to say hi and give us some feedback and suggestions!

Don’t forget to follow us on Twitter @Roshcast and @Roshreview. We can also be reached by email at roshcast@roshreview.com and are open to any feedback, corrections, or suggestions. You can help us pick questions by identifying ones you would like us to review. To do so, write “Roshcast” in the submit feedback box as you go through the question bank. And finally, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about Roshcast.

Until next time,
Jeff and Nachi