Q: 47 year old male in ICU went into supraventricular tachycardia (SVT) and successfully converted to NSR with total of 18 mg of Adenosine. On strip total Asystole time was 8 seconds. Now patient is complaing of numbness in upper extremities. What should be your next step?

Answer: Observation

Adenosine may make patients' limbs feel numb for few minutes after administration intravenously. Usually it happens when patient requires more than 12 mg of Adenosine. It usually resolves without any complication.

A note on balloon inflation volume of Pulmonary Artery catheter in patients with Pulmonary Hypertension

Pulmonary artery occlusion pressure (PAOP) - commonly know as wedge - is used to differentiate patients having pulmonary hypertension (PH) due to left-sided heart disease from other etiologies. 

One interesting study published in 2010 (see reference), investigated the PAOP measurements obtained from both pulmonary arteries with balloon full (1.5 mL) and half (0.75 mL) inflation in patients with suspected PH.

Study showed that PAOP can be falsely elevated in patients with PH according to the balloon inflation volume. Balloon half inflation was safe and correlated with higher precision and lower bias in the PAOP measurements.

Effect of Balloon Inflation Volume on Pulmonary Artery Occlusion Pressure in Patients With and Without Pulmonary Hypertension - CHEST January 2011 vol. 139 no. 1 115-121

Q: 47 year old male in ICU went into supraventricular tachycardia (SVT) and successfully converted to NSR with total of 18 mg of Adenosine. On strip total Asystole time was 8 seconds. Now patient is complaing of numbness in upper extremities. What should be your next step? 



Answer: Observation 

Adenosine may make patients' limbs feel numb for few minutes after administration intravenously. Usually it happens when patient requires more than 12 mg of Adenosine. It usually resolves without any complication.

A note on SVo2 and ScVo2

ScvO2 reflects principally the degree of oxygen extraction from the brain and the upper part of the body.

SvO2 reflects the relationship between whole-body O2 consumption and cardiac output.

Pitfall of ScVo2: The central venous catheter usually resides in the superior vena cava. Thus central venous blood sampling reflects the venous blood of the upper body but neglects venous blood from the lower body (i.e., intra-abdominal organs).  ScvO2 is usually less than SvO2 by about 2–3% because the lower body extracts less O2 than the upper body making inferior vena caval O2 saturation higher.

SvO2 and ScvO2 changes in parallel when the whole body ratio of O2 supply to demand is altered.

Q: How much time does oral Vitamin K take to be effective?


Answer: About 24 hours

In absence of active bleeding, oral Vitamin K is always preferable. Only disadvantage is its slow action. IV vitamin K takes about 6 to 12 hours to achieve expected INR and oral Vitamin requires about 24 hours.

Though IV vitamin is faster than oral Vitamin K, it carries the chances of anaphylactoid reaction even with minor dose. Also less known side effect of IV Vitamin K is over-correction of anticoagulation.

Comparison of Oral vs Intravenous Phytonadione (Vitamin K1) in Patients With Excessive Anticoagulation - A Prospective Randomized Controlled Study : Arch Intern Med. 2003;163(20):2469-2473.

Anaphylaxis after low dose intravenous vitamin K - J Emerg Med. 2003 Feb;24(2):169-72.

2 Phases of Amniotic Fluid Embolism (AFE)

Once the fluid and fetal cells enter the maternal pulmonary circulation, usually AFE presents as 2 phases.

First phase: The patient experiences acute shortness of breath which may lead to hypotension and cardiac arrest. It is said that half of women does not survive beyond this phase.

Second phase: Survivors of first phase will pass onto the second phase. This is known as the hemorrhagic phase and may be accompanied by severe shivering, coughing, vomiting, and the sensation of a bad taste in the mouth. This is accompanied by excessive bleeding due to DIC.

Treatment is mostly supportive.

Following is the protocol for Argatroban for patients effected with HIT (Heparin-induced thrombocytopenia)

Click here

Source:  Bon Secours Health System

Q: Why Heparin is called Heparin? 

 Answer: Heparin was discovered by a second-year medical student at Johns Hopkins University named Jay McLean, in 1916, when he isolated a fat-soluble phosphatide anti-coagulant in canine liver tissue. 'Hepar' is Greek for "liver", hence it was termed as Heparin.

Q: The Activated Clotting Time (ACT) is essentially a point of care test (POC) of coagulation that is used to monitor the anticoagulant effect of unfractionated heparin. (PTT is a 'send down' lab test). What is the ACT value in a non-anticoagulated patient? 


 Answer: In a non-anticoagulated patient, the ACT is in the region of 110s. During cardiopulmonary bypass, heparin is titrated to maintain an ACT between 400 to 600s. During ECMO, recommended value is between 200 and 240s

TandemHeart Training Video

Q: What are the classic findings in Ventricular Aneurysm repair?

Answer:Classic findings in Ventricular Aneurysm are

• first degree AV block
• left ventricular hypertrophy (LVH)
• right branch bundle block (RBBB)
• Q waves V1-V5, I, aVL with persistent ST elevations in these leads

View an EKG here: http://www.emergency-medicine-tutorials.org/Home/medical-3/cardiovascular/ecgs-1/ventricular-aneurysm

IVC filter migration to heart 

 Source: Inferior Vena Cava Filter Migration to the Right Ventricle: A Case Report and Review of Filter Migration and Misdeployment - Volume 2, Number 5, October 2011, pages 201-205 

weblink to source: http://www.journalmc.org/index.php/JMC/article/viewArticle/240/194

Figure. Lateral chest radiograph showing the location of the IVC filter in the heart (arrow).

A note on False positive Troponin I due to RF

Troponin complex is located on the thin filament of skeletal and myocardial muscle. The high sensitivity and specificity of cardiac troponin to detect myocardial injury is well documented. However, various factors can interfere with the TnI assay, leading to falsely elevated levels. This include particularly rheumatoid factor (RF).

Rheumatoid factor causes interference in the immunoassays. 5% of healthy people may have circulating rheumatoid factor, and approximately 1% of patients with elevated cardiac TnI levels may have this elevation solely because of the rheumatoid factor.


References:

1. Schifman, RB, James, SH, Sadrzadeh, SMH, et al Between-assay variation in false positive troponin I measurements in patients on renal dialysis or with positive rheumatoid factor - Clin Chem 1999;45,A145

2. Krahn, J, Parry, DM, Leroux, M, et al High percentage of false positive cardiac troponin I results in patients with rheumatoid factor. Clin Biochem 1999;32,477-480

Q: 48 year old male after crushing injury developed Rhabdomyolysis. At what day you expect CPK to peak?

Answer: Despite adequate treatment, CPK usually peaks on day 3 and decrease by half every 24-48 hours. It is clinically important to continue management.

Q: What added advantages Metformin offer in diabetic patients with cardiac morbidity? 

 Answer: Metformin is shown to reduce LDL and triglyceride levels. Moreover, unlike other anti-diabetics it is not associated with weight gain and is pretty safe in CHF patients.

Q: Mesothelioma can occur in which other organ beside pleura, pericardium and peritoneum? 


Answer: Testicles (Tunica Vaginalis layering)

Malignant mesothelioma is a tumor which arises in body cavities lined by mesothelium. Mostly these tumors are detected in the pleura, peritoneum and pericardium. As the tunica vaginalis is a layer of reflected peritoneum, mesothelioma can occur in the scrotal sac. The nonspecific symptoms and lack of tumor markers make diagnosis of malignant mesothelioma of the tunica vaginalis very difficult.

Peds critical care

 Q: Which diuretic carries anti epileptic property particularly in neonates? 

 Answer: Bumex 

 Bumetanide (Bumex) is a loop diuretic. In the brain, bumetanide blocks the NKCC1 cation-chloride co-transporter, and thus decreases internal chloride concentration in neurons. In turn, this concentration change makes the action of GABA more hyperpolarizing, which may be useful for treatment of neonatal seizures, that quite often are not responsive to traditional GABA-targeted treatment, such as barbiturates. Bumetanide is currently under evaluation as a prospective antiepileptic drug. 


http://clinicaltrials.gov/ct2/show/NCT00830531

Q: In nephrogenic diabetes insipidus (DI), thiazide diuretics are frequently used, which despite a diuretic causes an overall fluid conservation. But it may frequently lead to hypokalemia. Addition of which other diuretic may help? 


Answer: Amiloride 

 Desmopressin does not work in nephrogenic DI. A thiazide diuretic or indomethacin may improve nephrogenic diabetes insipidus. Thiazide diuretics are sometimes combined with amiloride to prevent hypokalemia. Amiloride has potassium-sparing capacities which often actually results in mild hyperkalemia.

Mnemonic of hypercalcaemia 

•  Stones (kidney or gallstones) 
•  Bones (bone pain) 
•  Groans (Gi pain and symptoms) 
•  Thrones (sit on throne - polyuria) 
•  Psychiatric overtones (Depression, anxiet, cognitive dysfunction, insomnia, coma)

Q: Although Vancomycin remained the treatment of choice for MRSA Pneumonia due to its high cost effectiveness, but what advantage does Zyvox (Linezolid) has over Vancomycin in lung related infections?


Answer: Linezolid is better than vancomycin against nosocomial pneumonia, like MRSA ventilator-associated pneumonia because the penetration of linezolid into bronchial fluids is much higher than that of vancomycin.

Other minor advatanges include high bioavailability, easy switching to oral therapy and no required adjustments in renal failure.

Q: Progesterone is also an “anticonvulsant.” True or false?

Answer: True

Catamenial epilepsy is defined as seizure exacerbation in women aligned with their menstrual cycle. It usually subsides in menopause and thought to be related to estrrogen. Progesterone is the mainstay of the treatment.

Q: What is Pagophagia?

Answer: Pagophagia is the compulsive consumption of ice or icey drinks. It has been very much associated and may be a presenting symptom of iron deficiency anemia. It gets resolved with iron supplementation.

There are 2 underlying resons for this pica. First, ice tastes better if the individual is iron deficient. Second, melting ice in mouth or chewing ice lessen pain in glossitis related to iron deficiency anemia.

Q: What is Beau's lines? 

Answer: Beau's line appear as transverse lines across the nail as signs of previous acute illnesses like severe infection, mayocardial infarction, any kind of shock, hypocalcemia, any big surgery, immunosuppressive therapy or chemotherapy and severe zinc deficiency. 

Mote interestingly, location on the nail may even provide the approximate date of the illness and the depth of the line provides a clue to the severity of the illness!

Q: 23 year old female presented to ER with severe anaphylaxis reaction after eating shrimp. Airway seems compromised. As you prepare and proceed with intubation, you encounter severe vocal cord edema with no inlet visible. What should be your next step? 

 Answer: Administration of Epinephrine 

 The 2010 Joint Task Force anaphylaxis parameter update, the 2011 World Allergy Organization anaphylaxis guidelines. It recommends cardiopulmonary monitoring, administration of oxygen and placement of a a large-bore IV, resuscitation with isotonic crystalloid, placing the patient in a supine position with the legs elevated and Epinephrine injection. 

Special and prompt attention should be paid to Airway. If severe vocal cord edema is encounter, repeat administration of epinephrine usually reverses the edema. Dose is 0.1-0.5 mg SC q10-15min. If edema persists, difficult airy protocol should be initiated.

Spontaneous Coronary Artery Dissection (SCAD)


SCAD is a rare condition characterised by an acute coronary syndrome in a patient whose age and sex suggest a low probability of atherosclerotic disease. Unfortunately, the natural history, particularly with proximal or extensive dissection, is unpredictable and warrants aggressive revascularisation.

Peripartum women are at increased risk due to changes in blood flow increasing shear stress, and progesterone driven vessel wall changes which may predispose to coronary dissection. Other risk factors involve Ehler-Dahnlos type IV, Marfan’s syndrome, strenuous exercise and drug induce like cocaine.

Treatment includes aspirin, B-blockers, +/- anticoagulants or glycoprotein IIb/IIIa inhibitors. Thrombolytic agents should be avoided as they may worsen the dissection process. Percutaneous intervention with deployment of a stent is the procedure of choice.  The potential for stent deployment into the false lumen exists!  Coronary artery bypass grafting remains the treatment of choice for very extensive, multi-vessel or the left main stem dissection.

Q: As you send pleural fluid to lab, initial report on computer reads -  pH =7.18 and glucose = 58 mg/dL. Nothing else reported yet. Whats your concern?



Answer:  Empyema


Usually empyema is tapped as frank pus or cloudy fluid from the pleural space. But it is very important to follow report on any thoracentesis as it is famously said that:

 "The Sun Should Never Set on an Empyema".

Drainage should be planned ASAP. In empyema the pleural fluid typically has a leukocytosis, low pH (less than 7.20), low glucose (less than 60 mg/dL), a high LDH, elevated protein and may grow infectious organisms.


http://chestjournal.chestpubs.org/content/95/5/945.full.pdf

Q: What is folded lung syndrome? 

 Answer: It is the other name of rounded atelectasis. As an outer portion of the lung slowly collapses as a result of scarring and shrinkage of the pleura, it produces a rounded appearance on x-ray. It may give apperance of a mass or tumor. Rounded atelectasis is usually a complication of asbestos-induced disease of the pleura, but it may also result from other types of chronic scarring and thickening of the pleura.

How to read Pulmonary Emboli on CT scan

 (step by step guide)

Q: Beside Ropinirole, which other dopamine agonist has good (or even better efficacy) in Restless Leg Syndrome? 


 Answer: Pramipexole 

Initial dose is 0.375 mg once daily. The dosage should be titrated to the desired clinical effect up to a maximum recommended dose of 4.5 mg per day.