Q: 74 year old with previous history of CHF developed atrial fibrillation with RVR (rapid ventricular rate) pre-operatively which was controlled with IV cardizem drip. Cardizem was continued. Patient developed signs and symptoms of Malignant Hyperthermia during surgery. IV dantrolene was administerated. Patient became hypotensive, developed V.Tach., collapsed and died?



Answer: Calcium channel blockers such as diltiazem (Cardizem) or verapamil may cause severe hemodynamic problems if concomittently administerated with Dantrolene. It may lead to severe cardiovascular collapse, arrhythmias, myocardial depressions, and hyperkalemia.

Q: 24 year old hiker is brought to ER after snakebite. Patient is reporting severe symptom of mint taste in his mouth. which snake is a likely culprit?


Answer: Rattlesnake

Victims complain of a "rubbery," "minty," or "metallic" taste if bitten by certain species of rattlesnake, after 30 to 90 minutes of attack.


Clinical significance: Rattlesnake bites can be poisonous and need rapid treatment i.e. administration of antivenin.

Q: What is Prothrombin complex concentrates (PCC)?


Answer: Prothrombin complex concentrates (PCC) are derived from human plasma and contain the vitamin K dependent coagulation factors II, VII, IX, and X at varying concentrations. Several international guidelines as well as American College of Chest Physicians, now recommends PCC for warfarin reversal in patients with serious bleeding. The use of PCC in the United States (US) is still not widespread.


Prothrombin Complex Concentrate Versus Standard Therapies for INR Reversal in Trauma Patients Receiving Warfarin - Ann Pharmacother July/August 2011 vol. 45 no. 7/8 869-875

Q: Thyrotoxic patients with atrial fibrillation

A) require a lower maintenance dose of warfarin than euthyroid patients

or

B) require a higher maintenance dose of warfarin than euthyroid patients

(Select one)

Answer: A Thyrotoxic patients may require a lower maintenance dose of warfarin than euthyroid patients in atrial fibrillation because of increased clearance of vitamin K–dependent clotting factors.



Fadel BM, Ellahham S, Ringel MD, et al. Hyperthyroid heart disease. Clin Cardiol 2000;23: 402–8.

Q: Cipro associated seizure can occur with

A) thyrotoxicosis
B) high doses of the drug, old age,
C) renal insufficiency,
D) drug interactions
E) electrolyte abnormalities,
F) history of seizure
G) Allof the above



Answer: All of the above

Objective of this question is to enhance the relatively less known risk factor of seizure associated with ciropfloxacin intake i.e, thyrotoxicosis. Unrelated to it, cipro itself can cause unexplained hypothyroidism.

Q: 44 year old male with history of seizure is admitted with breakthrough seizure and has been loaded with phenytoin. His regular dose has been increased. Since morning patient is complaining of vision problem. On examination he has opthalmoplegia. What is your concern?


Answer: Phenytoin overdose

One of the side effect of Phenytoin intoxication is ophthalmoparesis, also know as opthalmoplegia. This opthalmoplegia may take weeks to resolve.

Q: What is the pitfall of PO amiodarone (oral)?


Answer: When given orally, the bioavailability of amiodarone is very variable. Absorption ranges from 22 to 95%.

Amiodarone may better absorp when it is given with food.

Amiodarone induced optic neuritis!

Amiodarone is one of the most commonly used medicine in ICU. In past, we have done many pearls related to IV amiodarone.One of the other unusual and common presentation of Amiodarone toxicity is optic neuritis. Optic neuritis may occur at any time following initiation of therapy. If any symptoms of visual impairment appear, like change in visual acuity or decrease in peripheral vision, prompt ophthalmic consult is recommended.

Picture diagnosis

Q: 76 year old male is seen in ER with this x-ray after fall to rule out cranial fracture. Is this an artifact or real? 

Answer: It is deep brain stimulator surgically inplanted

Q: 76 year old male is admitted in ICU for Bradycardia secondary to beta-blocker prescribed for his essential tremor. You received nursing call at night that patient is now requesting alcohol to abort his symptoms of essential tremor as it is always helpful to him?


Answer: It is true that Alcohol decrease the synptoms of essential tremor. The mechanism of tremor reduction by alcohol is unknown.

The recommeded treatment is propranolol. And if propranolol is contraindicated, primidone is an alternative choice. Other drugs which have shown effects include Gabapentin, Clonazepam or Topiramate.

Surgical treatment is reserved for the severe cases include thalamotomy and deep brain stimulation.

Q: What is Dopamine dysregulation syndrome? 

 Answer: It is an interesting syndrome, may seen on people on long term Dopamine replacement therapy (DRT) like Levadopa in Parkinson's Disease. It is characterized by addiction to DRT medication (taking extra doses), gambling, hypersexuality, shopping, eating disorder, euphoria, psychosis etc. marked by periods in between of dysphoria, sadness, psychomotor slowing, fatigue, apathy etc., reulting from DRT withdrawal. One interesting symptom during euphoria phase is punding, repetition of complex motor behaviors such as collecting or arranging objects. 

Management is drug dose stratification.

Q: 22 year old male in ICU is admitted for unrelated reason, continue to show prolonged PTT but normal PT, Bleeding Time and Platelet count. Which disease process only prolonges PTT but all other normal basic coagulation profile?


Answer: Factor X11 deficiency

Factor X11 deficiency is also known as Hageman factor deficiency. It is very rare with evidence of about 1 in 1 million. Fortunately its a benign process, does not cause bleeding and normally do not need treatment. Even with major surgery, bleeding manifestations are extremely rare. Usually, it is diagnosed accidently by a prolonged activated partial thromboplastin time (aPTT) test.

PICC line insertion

PICC line under ultrasound

(2 parts)

Truvada

Truvada (Tenofovir/emtricitabine), is a fixed-dose combination of two antiretroviral drugs, consisting of 300 milligrams of tenofovir and 200 milligrams of emtricitabine. The drug has been just approved for use as a pre-exposure prophylaxis against HIV infection. It significantly decreased the risk of contracting HIV. It is approved for non-infected men who have sex with multiple male partners.

Side effects include nausea, vomiting, dizziness and renal toxicity. Also, Lactic acidosis, steatosis and post treatment exacerbation of Hepatitis B.

Q: What level of d-dimer along with clinical signs is predictive of Acute Aortic dissection?


Answer: In acute aortic dissection, usually level more than 500ng/ml is significant. In most cases, in acute aortic dissection this level is reported to be more than 2000ng/ml. D-dimer levels is useful in risk stratifying patients with suspected aortic dissection to rule out aortic dissection if used within the first 24 hours after symptom onset.

CXR clue for PE

CXR clue for PE

Note the uneven distribution of pulmonary blood flow between the two lungs with open vessels on Right. This patient had massive pulmonary embolism obstructing the left main pulmonary artery.

Q: 52 year old male presented to ER with massive PE. Diagnosis is confirmed with CT Angio and bedside Echo showed RV strain. You decided to use Thrombolytics. Pharmacy informed you that none of the FDA approved thrombolytics are available (Alteplase, Urokinase and Streptokinase). Only available thrombolytic is Reteplase? 


Answer: Although Reteplase has not been approved by the FDA for PE (only approved for AMI), but it is widely used off label for life threatening PE. The dosing used is the same as for patients with AMI: 2 IV boluses of 10 U each, administered 30 minutes apart. No adjustment is required for patient's weight. 

Actually, Reteplase work more rapidly and tends to have less bleeding risk than alteplase.

6 "Ps" of compartment syndrome

• Pain out of proportion,
• Paresthesia,
• Pallor,
• Paralysis,
• Pulselessness (+/-),
• Poikilothermia (failure to thermoregulate)

Neuroleptic Malignant Syndrome (NMS)

Mnemonic used to remember the features of NMS is FEVER.

• F – Fever
• E – Encephalopathy
• V – Vitals unstable
• E – Elevated enzymes – CPK
• R – Rigidity of muscles

Q: 52 year old male in ICU is under treatment for MRSA pneumonia with Zyvox (Linezolid). Patient was taken for "I n D" (incision and drainage) by surgery. Post-op patient has symptoms of shivering. Resident wrote order for Demerol. Pharmacy called you to confirm the order. What would be their concern? 



Answer: serotonin syndrome 

 Meperidine (Demerol) with linezolid (Zyvox) may cause serotonin syndrome with symptoms of confusion, hallucination, tachycardia, fever, sweating, muscle spasm etc.

Q: How much pleural fluid drainage is the indicator of successful Pleurodesis? 


Answer: less than 100-150 cc/24 hours

Q: Which artery is called "mother of all end arteries"?


Answer: Brachial artery

Due to its designation of sole supplier around elbow for downward areas, Brachial artery is called "mother of all end arteries". Before advent of ultrasound, arterial line insertion was highly discouraged in brachial artery, due to possible hematoma and nerve injury.

Still Radial and femoral artery are preferable over brachial artery for A-line insertion.

Lung Isolation

A note on Allen's test and Cardiac bypass surgery (CABG)


The radial artery is occasionally used as a conduit for bypass surgery, and its patency lasts longer in comparison to the saphenous veins. Prior to heart bypass surgery, Allen's test is performed to assess the suitability of the radial artery to be used as a conduit. A result of less than 3 seconds is considered as good and suitable. A result of between 3-5 seconds is equivocal, whereas the radial artery will not be considered for grafting if the result is longer than 6 seconds. A negative Allen’s test is safe to harvest the radial artery.


Is the Allen test reliable enough? - Eur J Cardiothorac Surg (2007) 32 (6): 902-905.

Q: What is "wedged blood PO2" and what is the clinical implication?

Answer: "Wedged blood Po2" is the level of PO2 while Pulmonary artery catheter baloon is inflated (wedging).

Wedge blood Po2 should be atleast 20 mm Hg higher than arterial PO2 (ABG) to confirm that you are measuring Pulmonary artery occlusion pressure at right level/spot.

Reference:
Paul L. Marino - The little ICU book of facts and Formulas, 2009 - Page 119

Q: What very essential piece of caution, seems missing most of the time, in femoral arterial line cannulation?

Answer: The femoral artery should always be accessed approximately 1 inch below the inguinal ligament, where it can be easily compressed. Unfortunately, many femoral arterial lines are placed/entered very high - near the inguinal ligament. In case of supra-inguinal bleed/injury, it becomes hard to control the bleeding by compression.

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Q: Nurse call you to evaluate the tongue of patient who is admitted with diagnosis of urosepsis?

Answer: Geographic Tongue!

Geographic tongue, also known as benign migratory glossitis, is an inflammatory condition of the tongue. It is characterized by discolored regions of taste buds. The condition usually manifests after eating exacerbating foods, or during times of stress, illness, or in women during menstruation. It is benign, appears and disappears frequently. It may cause some discomfort but no pain.

Q: What is the right time to check Anti-factor Xa levels in a renally impaired patients who is on q24 dosing?


Answer: Anti-Xa levels should be checked at their peak at 4 hours in all patients irrespective of dosing variations (both q12 and q24).