Q: While floating a Pulmonary Artery Catheter, as you  inflate balloon and enter right ventricle, nurse inform you that monitor is reading pressure 90/0. What is the problem?

Answer: Probably you are in left ventricle instead of right ventricle

Link: http://youtu.be/SvlK9XU7ThU

Q: What are the essential components of Decorticate and Decerebrate posturing

Answer:

Decorticate posturing:

• Elbows, wrists and fingers flexed
• Legs extended but rorated inwards

Decorticate posturing indicates damage to areas in cerebral hemispheres, the internal capsule, and the thalamus.

Decerebrate posturing:

• the head is arched back,
• the arms are extended by the sides (elbows extended),
• the legs are extended.

Decerebrate posturing indicates brain stem damage, specifically with lesions or compression in the midbrain and lesions in the cerebellum.

Progression from decorticate posturing to decerebrate posturing is often indicative of brain herniation.

Q: What is the recommended DVT prophylaxis in patients with no major risk undergoing spinal surgery?

Answer: For patients who have no major risk factors, antithrombotic prophylaxis following elective spine surgery is not recommended. 

Q: What are the added risk factors for pressure ulcer in ICU patients in addition to other hospitalized adult patients?

Answer:

1) Age

2) Length of ICU stay

3) Norepinephrine administration

4) Cardiovascular disease state

Please read following article and review on "Pressure Ulcer Management"

Cox J., - Predictors of pressure ulcers in adult critical care patients. - Am J Crit Care. 2011 Sep;20(5):364-75.

Link: http://www.aacn.org/wd/Cetests/media/a112005.pdf

Q: Ideally, how frequent lubricant should be applied in ICU patients, who have exposed cornea to prevent keratopathy/keratitis?

Answer: Some degree of keratopathy develops in about 60% of intubated and sedated patients. Incomplete lid closure increases the risk of corneal damage very high (70% vs. 30%). Fluid imbalance and positive pressure ventilation (Ventilator eye) may make it impossible to close eyelids completely. Lubricant should be applied ideally every two hours, particularly if any sort of cornea is exposed. Overall, literature lean more towards moist chamber application than lubricant application.

References:

1. Imanaka H, Taenaka N, Nakamura J, et al: Ocular surface disorders in the critically ill. Anesth Analg 1997; 85:343-346

2. McHugh J, Alexander P, Kalhoro A, et al: Screening for ocular surface disease in the intensive care unit. 2008;22:1465–1468

3. Mercieca F, Suresh P, Morton A, et al: Ocular surface disease in intensive care unit patients. Eye 1999; 13:231-236

4. Koroloff N, Boots R, Lipman J, et al: A randomized controlled study of the efficacy of hypromellose and Lacri-Lube combination versus polyethylene/Cling wrap to prevent corneal epithelial breakdown in the semiconscious intensive care patient. Intensive Care Med 2004; 6:1122-1126

5. Parkin B, Turner A, Moore E, et al: Bacterial keratitis in the critically ill. Br J Ophthalmol 1997; 12:1060-1063

6. Suresh P, Mercieca F, Morton A, et al: Eye care for the critically ill. Intensive Care Med 2000; 2:162-166

Q: 28 year old female is admitted to ICU with HELPP syndrome. Delivery was planned. Patient start complaining of bilateral blurring of vision. What could be the complication?

Answer: Retinal detachment

Retinal detachment is an unusual but very well documented complication of severe preeclampsia and patients with HELLP syndrome. Emergent ophthalmic consultation should be obtained along with planned delivery.

Reference:

1. McEvoy M, Runciman J, Edmonds DK, Kerin JF. Bilateral retinal detachment in association with preeclampsia. Aust N Z J Obstet Gynaecol 1981; 21: 246–247

2. Ramaesh K, Nagendran S, Saunders DC. Choroidal ischaemia and serous retinal detachment in toxaemia of pregnancy. Eye 1999; 13: 795–796

3. Sibai BM, Ramadan MK, Usta I, Salama M, Mercer BM, Friedman SA. Maternal morbidity and mortality in 442 pregnancies with haemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol 1993; 169: 1000–1006

Q: What is Palla's sign in Pulmonary Embolism (PE)?

Answer: A chest x-ray shows a prominent right descending pulmonary artery, along with an area of focal oligemia (Westermark’s sign).

Q: 45 year old female with established diagnosis of pheochromocytoma and on maintenance dose of phenoxybenzamine - presented with septic shock. Which pressors may not work on her?

Answer: Epinephrine and Norepinephrine

Phenoxybenzamine forms a permanent covalent bond with adrenergic receptors. It remains permanently bound to the receptor, preventing adrenaline and noradrenaline from binding. This causes vasodilatation, due to its antagonistic effect at the alpha-1 adrenoceptor.

Q: What advantage plasma exchange provides in acute exacerbation of Wegner's Granulomatosis?

Answer: It does not improve mortality but may rescue renal failure

Reference:

1.Klemmer PJ, Chalermskulrat W, Reif MS, et al. Plasmapheresis therapy for diffuse alveolar hemorrhage in patients with small-vessel vasculitis. Am J Kidney Dis 2003;42:1149–1153.

2.Nguyen T, Martin MK, Indrikovs AJ. Plasmapheresis for diffuse alveolar hemorrhage in a patient with Wegener's granulomatosis: case report and review of the literature. J Clin Apher 2005;20:230–234.

Q: What is the recommendation for giving Haldol (Haloperidol) in patients over age 65? 

Answer: Haldol should be use with caution in elderly patients. Doses should be smaller in 0.25 - 0.5 mg range, and ideally should not exceed more than 2 mg over 24 hours period.

Q: What is the clinical utility of doing free plasma Hemoglobin? 

Answer: Plasma normally contains no free hemoglobin. Significant amounts of hemoglobin occur in plasma following hemolysis either from a transfusion reaction or any mechanical fragmentation of red blood cells.

Caution should be taken not to perform test on serum, as hemoglobin gets liberated from red blood cells during clotting. Moreover, elevated bilirubin levels interfere with the quantitation of the total plasma hemoglobin.

Reference:

Fairbanks VF, Ziesmer SC, O'Brien PC: Methods for measuring plasma hemoglobin in micromolar concentration compared. Clin Chem 1992;38:132-140

Q: You have been called to ER to evaluate a patient with severe headache. You ruled out SAH (Subarachnoid hemorrhage) with radiological imagings and you strongly suspect acute migraine. What one non-narcotic medicine may help you to treat severe acute migraine? 

Answer: Metoclopramide

A meta-analysis of 13 randomized controlled trials concluded that intravenous metoclopramide should be considered a primary agent in the treatment of migraine in emergency departments.

Reference:

Colman I, Brown MD, Innes GD, Grafstein E, Roberts TE, Rowe BH. Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials. BMJ. 2004;329(7479):1369–1373

Q: "Worst headache of life" or "like being kicked in the head" is the classic presentation in SAH (Subarachnoid hemorrhage) . Many patients report neck stiffness too. What is the usual lag time reported between headache and neck stiffness, and strongly suggests SAH?

Answer: About 6 hours.

In classic SAH presentation, neck stiffness usually presents six hours after initial onset of SAH.

Reference:

Warrell, David A; Timothy M. Cox, et al. (2003). Oxford Textbook of Medicine, Fourth Edition, Volume 3. Oxford. pp. 1032–34

Q: Which patient population is at highest risk of developing HIT (Heparin Induced Thrombocytopenia)?

Answer: 

Female Gender receiving heparin after a recent surgical procedure, particularly cardiothoracic surgery.

Q: Patient's platelet count suddenly dropped from 283 k/uL to 25 k/uL. Patient is clinically stable and you expect pseudothrombocytopenia. What would be your instruction to nursing staff while repeating lab?

Answer: Send second blood sample with 'blue top'

Most pseudothrombocytopenia has been reported in association with the use of ethylenediaminetetraacetic acid (EDTA) as an anticoagulant. A second sample run with a different anticoagulant such as citrate (blue top tube) usually helps to rule out the error.

Q: In Dengue virus shock syndrome, what should triggers the blood transfusion?

Answer:

In contrast to other clinical situations, Blood transfusion should be initiated early in hemodynamically unstable patients suffering from Dengue virus shock syndrome,                           in the face of a decreasing hematocrit, rather than following hemoglobin concentration.

WHO (2009). Dengue Guidelines for Diagnosis, Treatment, Prevention and Control: Geneva: World Health Organization. 

Q: 52 year old male while on trip to Arizona encountered Scorpion sting and probable Envenomation. Patient is intubated in field and transferred to ED. Anascorp (only commercially available anti venom for scorpion bite) has been administered. Which factors should keep you on high alert for anaphylactic reaction from Scorpion anti venom administration?

Answer:

Anascorp® is made from equine (horse) plasma. Patients with known allergies to horse protein are particularly at risk for an anaphylactic reaction. Patients who have had previous therapy with Anascorp® or another equine antivenom/antitoxin may have become sensitized to equine proteins and be at risk for a severe hypersensitivity reaction.

GET SMASHED

The mnemonic GETSMASHED is used for common causes of Pancreatitis:

G - Gall stones

E - Ethanol

T- Trauma

S - Steroids

M - Mumps

A - Autoimmune

S - Scorpion sting

H - Hyperlipidaemia, Hypothermia, Hyperparathyroidism

E - ERCP

D - Drugs

Q: What is the advantage of intraduodenal feeding beside less chances of aspiration pneumonia?

Answer: Intraduodenal feeding causes

• a stronger GI response than intragastric feeding
• stimulates gallbladder contractions,
• accelerates small bowel transit time, and
• increases cholecystokinin and pancreatic polypeptide release

(In contrast, jejunal feeding does not stimulate pancreatic secretion, as is seen in intragastric or intraduodenal feeding)

 

Reference:

1. Ledeboer M, Masclee AA, Biemond I, Lamers CB. Effect of intragastric or intraduodenal administration of a polymeric diet on gallbladder motility, small-bowel transit time, and hormone release. Am J Gastroenterol. 1998;93:2089–2096

2. Ragins H, Levenson SM, Signer R, Stamford W, Seifter E. Intrajejunal administration of an elemental diet at neutral pH avoids pancreatic stimulation. Studies in dog and man. Am J Surg. 1973;126:606–614

Q: What is the dose of Methylene blue (MB) in Vasoplegic Syndrome?

Answer: A single dose of IV MB, 2 mg/kg over 20-min infusion. Continuous MB infusion could be an option for patients not responding to a single dose of MB.

Reference:

Leyh RG, Kofidis T, Strüber M, Fischer S, Knobloch K, Wachsmann B, Hagl C,Simon AR, Haverich A. Methylene blue: the drug of choice for catecholamine-refractory vasoplegia after cardiopulmonary bypass. J Thorac Cardiovasc Surg 2003;125:1426-1431

A note on Magnesium level and Hemolysis

Magnesium concentrates in erythrocytes almost three times more than in serum. Hemolysis can increase plasma magnesium. Hypermagnesemia is expected only in massive hemolysis. The serum Mg is expected to rise by 0.1 mEq/L for every 250 mL of erythrocytes that lyse completely, so hypermagnesemia is expected only with massive hemolysis.

Q: What is the most important clinical relevance of TTKG (The trans-tubular potassium gradient)?

Answer: TTKG is calculated by following formula

TTKG = urine K+ X serum osmolality/serum K+ X urine osmolality

• A TTKG of greater than 8 indicates that aldosterone is present and that the collecting duct is responsive to it.
• A TTKG of less than 5 in the presence of hyperkalemia indicates aldosterone deficiency or resistance.

Q: What is the typical increase in potassium level after usual dose administration of  succinylcholine? 

Answer:  A typical increase of potassium ion serum concentration on administration of succinylcholine is 0.5 mmol per litre

Q: What is the dose of Ketamine in RSI (Rapid Sequence Intubation)?

Answer: Ketamine is given intravenously - 1 to 2 mg/kg. In patients with severe shock, half or even one fourth of dose has been advocated by some.

It has a time to effect of 45 to 60 seconds, and a duration of action of 10 to 20 minutes.

Ketamine has all good properties for use in "awake intubation" or in "possible difficult intubation".  It preserves respiratory drive, has a quick onset of action, good hemodynamic profile and has an analgesic properties. 

The reemergence phenomenon (disturbing dreams) as patient emerges from ketamine-induced anesthesia, limits use of the drug for procedural sedation. Rreemergence phenomena can be decrease with concomitant use of a benzodiazepine