Tuesday, July 31, 2018


Q: 4-Factors Prothrombin complex concentrate (Brand Name:Kcentra) contains all of the following except

A) Factors II
B) Factor VIII
C) Factor IX
D) Factor X
E) Protein C and Protein S

Answer: B

The objective of above question is to highlight the fact that despite it's name '4-Factors Prothrombin complex concentrate', it also contains Protein C and S.

'KCentra' contains  Factors II, VII (not VIII), IX and X.



Kcentra (prothrombin complex concentrate human) [prescribing information]. Kankakee, IL: CSL Behring; August 2017.

Monday, July 30, 2018

Decreasing "death rattle"

Q: All of the following are good options to decrease "death rattle" at the end of the life care except?

A) Glycopyrrolate 0.1 mg SL q 6 hours/PRN
B) Scopolamine transdermal 1.5 mg patch q 72 hours
C)) Atropine 0.4 to 0.6 mg SC q 4-6 hours/PRN
D) Atropine 1-2 drops 1% ophthalmic solution given SL q 2-4 hours/PRN
E) Epinephrine 0.5 mg SC q 4-6 hours/PRN


"Death rattle" - sound from upper airway secretions are of distress to a patient as well as to the family. It may also increase the risk of pneumonia in a patient going through the last stages of life.  Before applying the pharmacologic treatment, it would be appropriate to provide emotional support, logical explanation, proper positioning, and cleaning the mouth.

All of the above pharmacological interventions are good options except choice E. Epinephrine has no role in such scenario, rather contra-indicated.

Indeed, choice D is interesting. 3



1.  Bennett M, Lucas V, Brennan M, et al. Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. Palliat Med 2002; 16:369. 

2. Kintzel PE, Chase SL, Thomas W, et al. Anticholinergic medications for managing noisy respirations in adult hospice patients. Am J Health Syst Pharm 2009; 66:458. 

3. Protus BM. Evaluation of atropine 1% ophthalmic solution adminstered sublingually for the management of terminal respiratory secretions. Am J Hosp Palliat Care 2013; 30:388.

Sunday, July 29, 2018

electrical cardioversion for atrial fibrillation

Q: The success rate of electrical cardioversion for atrial fibrillation (AF) is inversely proportional to? (select one)

A) The size of the left atrium

B) The size of the right atrium

Answer: A

Overall, the success rate of electrical cardioversion for Atrial Fibrillation depends on two factors: 1) How long the AF is present (duration), and 2) the size of the left atrium. Moreover, the use of biphasic cardioversion works better than the use of monophasic cardioversion.



1.  Lown B. Electrical reversion of cardiac arrhythmias. Br Heart J 1967; 29:469. 

2. Gurevitz OT, Ammash NM, Malouf JF, et al. Comparative efficacy of monophasic and biphasic waveforms for transthoracic cardioversion of atrial fibrillation and atrial flutter. Am Heart J 2005; 149:316. 

Saturday, July 28, 2018

Post-dural puncture headache

Q: All of the following are associated with a post-lumbar puncture (LP) headache or more accurately a post-dural puncture headache (PDPH) except

A) Female gender 
B) Pregnancy 
C) History of prior headaches 
D) High opening pressure 
E) Low body mass index (BMI) 

 Answer: D

Contrary to popular belief, the lower the opening pressure during LP the higher the risk of PDPH, as there is more chance of cerebrospinal (CSF) fluid hypotension which subsequently causes venous dilatation/congestion, the actual reason behind a headache. 



Vilming ST, Schrader H, Monstad I. The significance of age, sex, and cerebrospinal fluid pressure in post-lumbar-puncture headache. Cephalalgia 1989; 9:99.

Friday, July 27, 2018

Thyroid storm and calcium metabolism

Q: Thyroid storm is usually associated with? (select one)

A) Hypocalcemia
B) Hypercalcemia

Answer: B

Though not diagnostic but various biochemical abnormalities are supportive of suspected thyroid storm in patients with suppressed TSH and elevated T3 or/and T4. It includes hypercalcemia, abnormal liver enzymes, hyperglycemia, leukocytosis, or leukopenia. Hypercalcemia, as expected, is from hemoconcentration and increased bone resorption.



Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am 2006; 35:663.

Thursday, July 26, 2018

Complications of CRRT

Q: All of the following are the complications of Continuous Renal Replacement Therapy (CRRT) except?

A) Electrolyte imbalance
B) Acid-base imbalances
C) Hypotension
D) Infection
E) Hyperthermia

Answer:  E

There are many factors which lead to hypothermia during CRRT. About 150-200 mL of blood is staying outside the body at any given time. Also, replacement fluid and dialysate are at the bedside at room temperature. Rotation of such relatively larger volume contributes to hypothermia. Clinically, this induced hypothermia comes with its own price with clotting dysfunction 3, fibrinolysis, masking of infectious fever and in some cases arrhythmias.

Hypothermia can be avoided with the use of a blood warmer in the circuit but most systems have some type of plate or convective warmer for warming the therapy fluids. 4



1. Jones SK. Loss of body heat during continuous venovenous hemodialysis (CVVHD) in critically ill patients. Blood Purif. 2003; 21:183–207. 

2. Yagi N, LeBlanc M, Sakai K, Wright EJ, Paganini EP. Cooling effect of continuous renal replacement therapy in critically ill patients. Am J Kidney Dis. 1998;32:1023–1030.

3. Wolberg AS, Meng ZH, Monroe DM III, Hoffman M. A systemic evaluation of the effect of temperature on coagulation enzyme activity and platelet function. J Trauma. 2004;56:1221–1228

4. Rickard CM, Couchman BA, Hughes M, McGrail MR. Preventing hypothermia during continuous venovenous haemodiafiltration: a randomized controlled trial. J Adv Nurs. 2004;47:393–400.

Wednesday, July 25, 2018

Acetaminophen as a prophylaxis against PONV

Q: Acetaminophen (Tylenol/Paracetamol) can be used as a prophylaxis against post operative nausea vomiting (PONV)?

A) True
B) False

Answer: A

Meta-analysis published by Apfel Et al comprising of 2364 patients showed that if IV acetaminophen given prophylactically before arrival to recovery unit, it reduced the PONV in proportion with the reduction of pain (odds ratio 0.66, 0.47-0.93) (P=0.02) and vomiting (P=0.006).



 Apfel CC, Turan A, Souza K, Pergolizzi J, Hornuss - Intravenous acetaminophen reduces postoperative nausea and vomiting: a systematic review and meta-analysis. Pain. 2013 May;154(5):677-89.

Tuesday, July 24, 2018

Phase 4 trial

Q: What is Phase 4 trial of any given drug?

Answer:  Relatively less publicised and less talked is the evaluation of a drug profile after it is approved and already in the market for patients. It looks over the time the efficiency and the side effects of a new drug/treatment. Usually, it is carried out over a longer period of time and look over thousands of patients.



Suvarna V. Phase IV of Drug Development. Perspectives in Clinical Research. 2010;1(2):57-60.

Monday, July 23, 2018

"Palm Method"

Q: How the "palm method" can be quickly used in estimating a Body Surface Area (TBSA) in patients? 


  • The palm of the patient's hand excluding the fingers is about 0.5 percent of total body surface area.
  • The palm of the patient's hand including the fingers is about 1 percent of total body surface area.
Above-said, although this is a quick method of TBSA but is not a very reliable one.



1. Sheridan RL, Petras L, Basha G, et al. Planimetry study of the percent of body surface represented by the hand and palm: sizing irregular burns is more accurately done with the palm. J Burn Care Rehabil 1995; 16:605. 

2. Nagel TR, Schunk JE. Using the hand to estimate the surface area of a burn in children. Pediatr Emerg Care 1997; 13:254.

Sunday, July 22, 2018

Ambulation in DVT

Q: Patients with the diagnosis of acute deep venous thrombosis (DVT) should not be mobilized for 48 hours to avoid pulmonary embolism (PE)? 

A) True
B) False

Answer: B

Evidence does not support bed rest for patients with acute DVT. Early embolization does not convert DVT into PE. Though very aggressive physical therapy should not be pursued. Moreover, compression stockings may actually be helpful.



1. Aschwanden M, Labs KH, Engel H, et al. Acute deep vein thrombosis: early mobilization does not increase the frequency of pulmonary embolism. Thromb Haemost 2001; 85:42. 

2. Anderson CM, Overend TJ, Godwin J, et al. Ambulation after deep vein thrombosis: a systematic review. Physiother Can 2009; 61:133. 

3. Aissaoui N, Martins E, Mouly S, et al. A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int J Cardiol 2009; 137:37. 

4. Partsch H, Blättler W. Compression and walking versus bed rest in the treatment of proximal deep venous thrombosis with low molecular weight heparin. J Vasc Surg 2000; 32:861.

Saturday, July 21, 2018

Cardioversion during pregnancy

Q; Cardioversion during pregnancy affects the rhythm of the fetus and fetus should be delivered prior to cardioversion?

A) True 
B) False

Answer:  B

Cardioversion can be performed safely during pregnancy and it does not affect fetus' rhythm, though it is recommended that the fetal heart rate is monitored.



1.vogel jh, pryor r, blount sg jr. direct-current defibrillation during pregnancy. jama 1965; 193:970.

2. Schroeder JS, Harrison DC. Repeated cardioversion during pregnancy. Treatment of refractory paroxysmal atrial tachycardia during 3 successive pregnancies. Am J Cardiol 1971; 27:445.

Friday, July 20, 2018

vagal responses

Q: Nasogastric tube placement (select one)

A)  increases the vagal tone
B) decreases the vagal tone

Answer: A

Various bedside maneuvers can cause increased vagal responses and may have undesired effects. It include prolonged sinus pauses or even asystole, atrioventricular blocks, or hemodynamic instability. Induction of  atrial fibrillation has been reported too. Carotid sinus massage may lead to stroke or transient ischemia attack (TIA).

Some common vagal maneuvers include carotid sinus massage, valsalva maneuver, eyeball pressure, breath holding, rectal exam, coughing, deep respirations, gagging, vomiting, swallowing, nasogastric (NG) tube placement and trendelenburg position.



1. Yamakawa K, So EL, Rajendran PS, et al. Electrophysiological effects of right and left vagal nerve stimulation on the ventricular myocardium. Am J Physiol Heart Circ Physiol 2014; 307:H722.

2. Davies AJ, Kenny RA. Frequency of neurologic complications following carotid sinus massage. Am J Cardiol 1998; 81:1256.

Thursday, July 19, 2018

On formula for the calculation of serum osmolality

Q; Why serum sodium is multiplied by 2 in the formula for the calculation of serum osmolality (Sosm)? 

 Calculated Sosm = (2 x serum [Na]) + [glucose]/18 + [BUN]/2.8 + [ethanol]/3.7 


The serum sodium is multiplied by two in the formula to calculate serum osmolality is to account for accompanying anions (usually chloride and bicarbonate).

Moreover the divisors - 18, 2.8 and 3.7 - in the formula are to convert units of mg/dL to mosmol/kg 

When international units (mmol/L) are used, formula for 
Calculated Sosm = (2 x serum [Na]) + [glucose] + [urea] + (1.25 x [ethanol])



1. Lynd LD, Richardson KJ, Purssell RA, et al. An evaluation of the osmole gap as a screening test for toxic alcohol poisoning. BMC Emerg Med 2008; 8:5. 

2. Purssell RA, Pudek M, Brubacher J, Abu-Laban RB. Derivation and validation of a formula to calculate the contribution of ethanol to the osmolal gap. Ann Emerg Med 2001; 38:653.

Wednesday, July 18, 2018

Diuretic dose in CHF exacerbation

Q: 62 year old male with history of congestive heart failure (CHF) and previously stable on home medications  presented with acute exacerbation of CHF requiring Non Invasive Positive Pressure Ventilation (NIPPV). The recommended required dose of diuretic for this patient?

A) As equal as home dose
B) About 2.5 times of home dose
C) Start with lowest dose 
D) furosemide drip with 10 mg/hr
E) Add metolazone to home diuretic dose

Answer: B

Patients with acute exacerbation of CHF who are chronically on diuretics at home usually requires about 2.5 times of their baseline total daily dose. This came from the DOSE trial which showed benefit towards improved clinical symptoms in patients in higher dose arm of the study.

Continuous IV infusion can be initiated but requires IV bolus dose prior to it (choice D).

Metolazone is usually added as a second step when response to diuretic is not desirable (choice E).



Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011; 364:797.

Tuesday, July 17, 2018

transvalvular left ventricular assist device

Q: Which of the following is percutaneous transvalvular left ventricular assist device?

A) Percutaneous left atrial-to-femoral arterial ventricular assist device (Tandem Heart ©)
B) Fem-Fem Extracorporeal membrane oxygenator (ECMO)
C) Percutaneous left ventricular assist device (Impella ©)
D) Intra-aortic Balloon Pump (IABP)
E) Pulmonary artery catheter (Swan-Ganz or PAC)

Answer: C

Tandem Heart © is placed via the femoral vein and across the interatrial septum to provide circulatory support. (choice A)

Bilateral femoral cannulas for ECMO do not cross any heart valve. (choice B)

Impella © is placed retrograde via the femoral artery, crosses the aortic valve into the left ventricle, unload the ventricle into the aorta. (choice C)

IABP never reaches the heart. (choice D)

PAC is a diagnostic tool, not a therapeutic tool or an assisted device. (choice E)



Lauten A, Engström AE, Jung C, et al. Percutaneous left-ventricular support with the Impella-2.5-assist device in acute cardiogenic shock: results of the Impella-EUROSHOCK-registry. Circ Heart Fail 2013; 6:23.

Monday, July 16, 2018

Ultrasound of lungs - review

Q: What does "shred sign" signifies on lung ultrasound?

Answer:  Many times consolidations in lung may get missed via regular chest X-ray particularly only on supine films in ICUs. Ultrasound has an advantage to pick those hidden consolidations. It can be picked by the irregular, shaggy border between the consolidated and normally aerated lung and is known as “shred sign”.

Beautiful pictorial review on ultrasound of lungs here

Link: https://goo.gl/9WEL3j

Reference: Chichra A, Makaryus M, Chaudhri P, Narasimhan M. Ultrasound for the Pulmonary Consultant. Clinical Medicine Insights Circulatory, Respiratory and Pulmonary Medicine. 2016;10:1-9.

Sunday, July 15, 2018

Peritoneal Dialysis Catheter ESIs

Q: 27 year old male on kidney transplant list and now on peritoneal dialysis is admitted for sepsis and hypotension after his weekend trip to the water park. The probable source of sepsis appears to be a peritoneal dialysis catheter exit site. Surgical service is consulted in addition to initiation of antibiotics and continuous renal replacement therapy (CRRT). All of the following are considered as preventive measures to decrease exit site infections (ESIs) except?

A) Daily topical antibiotic at the exit site
B) Daily topical nasal antibiotics
C) Cover the exit site with an ostomy bag while swimming
D) Discourage pets at house
E) Regular cleaning of the exit site with chlorhexidine solution

Answer: B

The objective of the above question is to emphasize that regular application of nasal antibiotics do not decrease the infection rate in patients with chronic catheter insertion.  Also, another objective of the above MCQ is to highlight the risk of zoonotic infections as a probable cause of sepsis in such patients (choice D).



1. Szeto CC, Li PK, Johnson DW, et al. ISPD Catheter-Related Infection Recommendations: 2017 Update. Perit Dial Int 2017; 37:141.

2.  Broughton A, Verger C, Goffin E. Pets-related peritonitis in peritoneal dialysis: companion animals or trojan horses? Semin Dial 2010; 23:306.

Saturday, July 14, 2018

Fluorescence bronchoscopy

Q: What is Fluorescence bronchoscopy?

Answer:  Fluorescence bronchoscopy can detect pre-invasive lesions such as squamous cell carcinoma which develops a fluorescent property. When combined with the regular bronchoscopy it increases the detection of airway preinvasive lesions, particularly high grade, and biopsies can be taken at the same time. Though technology is still in its nascent stages and has not been studied well it is a hope that by detecting lesions earlier it will reduce the morbidity and mortality of lung cancers.


References/further reads:

1. Kurie JM, Lee JS, Morice RC, et al. Autofluorescence bronchoscopy in the detection of squamous metaplasia and dysplasia in current and former smokers. J Natl Cancer Inst 1998; 90:991. 1

2. Edell E, Lam S, Pass H, et al. Detection and localization of intraepithelial neoplasia and invasive carcinoma using fluorescence-reflectance bronchoscopy: an international, multicenter clinical trial. J Thorac Oncol 2009; 4:49.

3. Banerjee AK, Rabbitts PH, George J. Lung cancer. 3: Fluorescence bronchoscopy: clinical dilemmas and research opportunities. Thorax 2003; 58:266.

4. Ikeda N, Honda H, Hayashi A, et al. Early detection of bronchial lesions using newly developed videoendoscopy-based autofluorescence bronchoscopy. Lung Cancer 2006; 52:21.

5.Chiyo M, Shibuya K, Hoshino H, et al. Effective detection of bronchial preinvasive lesions by a new autofluorescence imaging bronchovideoscope system. Lung Cancer 2005; 48:307.

6. Loewen G, Natarajan N, Tan D, et al. Autofluorescence bronchoscopy for lung cancer surveillance based on risk assessment. Thorax 2007; 62:335.

Friday, July 13, 2018

pulmonary function score ratio (PFS ratio) in Guillain-Barré syndrome

Q: How pulmonary function score ratio (PFS ratio) helps in patients with Guillain-Barré syndrome?

Answer: Calculating pulmonary function score ratio (PFS ratio) in patients with Guillain-Barré syndrome may guide into the time of tracheostomy as it predicts the length of intubation.

PFS = VC (in mL/kg) + MIP (in cm H2O) + MEP (in cm H2O)

VC = vital capacity
MIP =  maximal inspiratory pressure 
MEP = maximal expiratory pressure. 

The PFS ratio: is obtained by dividing PFS immediately prior to intubation and PFS on the 12th day of mechanical ventilation. 

A PFS ratio < 1  predicts the need for mechanical ventilation for more than 3 weeks with the specificity of 100 percent.



Lawn ND, Wijdicks EF. Post-intubation pulmonary function test in Guillain-Barré syndrome. Muscle Nerve 2000; 23:613.

Thursday, July 12, 2018

ARDS and aerosol delivery

Q: All of the following are the effects of prone positioning in Acute Respiratory Distress Syndrome (ARDS) except? 

A)  Improved configuration between lung and thorax 
B) Less abdominal pressure 
C) Improved secretion mobilization 
D) Decreased aerosol delivery
E) More homogeneous perfusion 

Answer: D

Although prone positioning is around for a while it tool few decades to understand the physiologic effects and a proper way to operate it. Recently, this results in evidence-based literature leaning towards its application in severe ARDS particularly prior to application of extracorporeal membrane oxygenation (ECMO). All of the above are the effects of prone position except D as prone position increase/improve the aerosol delivery due to reopening of the more alveoli.


Oczenski W, Hörmann C, Keller C, et al. Recruitment maneuvers during prone positioning in patients with acute respiratory distress syndrome. Crit Care Med 2005; 33:54.

Wednesday, July 11, 2018

hypertriglyceridemia and pseudohyponatremia.

Q: Severe hypertriglyceridemia may cause pseudohyponatremia. What is the usual correlation? 

Answer: On average, an 886 mg/dL increase in plasma triglycerides reduces the serum sodium concentration by approximately 1 mEq/L.



Dimeski G, Mollee P, Carter A. Effects of hyperlipidemia on plasma sodium, potassium, and chloride measurements by an indirect ion-selective electrode measuring system. Clin Chem 2006; 52:155.

Tuesday, July 10, 2018

QT Interval measurement preferred lead

Q: Which leads in EKG are preferred to measure the QT interval?

Answer: Leads II and V5 

Lead II and lead V5 is preferred due to the fact that termination of T waves is most clearly visible in these leads, which makes these leads best to measure reliable QT interval.



Cowan JC, Yusoff K, Moore M, et al. Importance of lead selection in QT interval measurement. Am J Cardiol 1988; 61:83.

Monday, July 9, 2018

Antimicrobial bladder irrigation

Q: Urinary bladder irrigation is a common procedure used in ICUs. Antimicrobial irrigation has been proposed. Evidence based literature shows that antimicrobial irrigation of the bladder (select one)

A) prevent the urinary tract infections
B) Delay the urinary tract infections
C) Increases the risk for urinary tract infections
D) No effect on urinary tract infections

Answer: C

Antimicrobial irrigation of the bladder does not prevent or delay the urinary tract infections (UTIs), rather studies have shown that it may increase the risk for UTIs. Also, it may subject patients to develop more resistance to the organisms. Irrigation with sterile saline is perfectly acceptable.



1. Warren JW, Platt R, Thomas RJ, et al. Antibiotic irrigation and catheter-associated urinary-tract infections. N Engl J Med 1978; 299:570. 

Sunday, July 8, 2018

Bicarb and ECF volume

Q: A 50 mL ampule of 50 mEq of sodium bicarbonate (popularly known as "1 amp of bicarb") expands the Extra Cellular Fluid (ECF) volume by approximately 

A) 50 mL 
B) 100 mL
C) 250 mL.
D) 500 mL
E) unpredictable

Answer: C

"one amp of bicarb" expands the ECF volume by approximately 250 mL, which is approximately equivalent to one IVF bolus!



Alpern RJ, Cogan MG, Rector FC. Effects of extracellular fluid volume and plasma bicarbonate concentration on proximal acidification in the rat. Journal of Clinical Investigation. 1983;71(3):736-746.

Saturday, July 7, 2018

PEEP in venous air embolism

Q: During the management of venous air embolism (VAE), with an intubated patient, positive end-expiratory pressure (PEEP) should be (select one)

A) increased
B) optimized by running pressure-volume (PV) loop on ventilator
C) discontinued
D) May keep PEEP at 5 cm H2O
E) C and D

Answer: E

Increasing the PEEP increases the chance of an intracardiac right-to-left shunt, which may convert a VAE into a paradoxical air embolism (PAE), a life-threatening complication (choice A). During VAE there is no luxury of time to run PV loop (choice B).

There is a lot of debate between choices C and D but evidence is very weak to recommend to discontinue the PEEP (choice C) though it can be done if danger of hypoxemia is not anticipated. Ans, some studies have suggested a benefit of (regular) PEEP in prevention of VAE.

Objective of the above question is to highlight the controversy of PEEP in the management of VAE



1. Meyer, PG Cuttaree, H Charron, B Jarreau, MM Peri, AC Sainte-Rose, C Perkins NA, Bedford RF: Hemodynamic consequences of PEEP in seated neurological patients: Implications for paradoxical air embolism. Anesth Analg 1984; 63:429–32

2. Perkins, NA Bedford, RF Zasslow MA, Pearl RG, Larson CP, Silverberg G, Shuer LF: PEEP does not affect left atrial-right atrial pressure difference in neurosurgical patients. Anesthesiology 1988; 68:760–3

3. Zasslow, MA Pearl, RG Larson, CP Silverberg, G Shuer, LF Schmitt HJ, Hemmerling TM: Venous air emboli occur during release of positive end-expiratory pressure and repositioning after sitting position surgery. Anesth Analg 2002; 94:400–3

4. Schmitt, HJ Hemmerling, TM Giebler R, Scherer R, Erhard J: Effect of positive end-expiratory pressure on the incidence of venous air embolism and on the cardiovascular response to the sitting position during neurosurgery. Br J Anaesth 1998; 80:30–5Giebler, R Scherer, R Erhard, J

Friday, July 6, 2018

response of benzodiazepine in convulsive status epilepticus

Q: How long one should wait to see the response of  benzodiazepine in patients with convulsive status epilepticus before administrating the repeat dose?

Answer:  one minute

First line of treatment in patients with convulsive status epilepticus is lorazepam with either the calculated dose of 0.1 mg/kg IV (2 mg/min) or a 4 mg fixed dose. It takes about one minute to see the full response of lorazepam as it is a lipophilic drug. If intravenous access is not available In the pre-hospital 10 mg of intramuscular (IM) midazolam can be given as an alternative.



Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17:3.

Thursday, July 5, 2018

Lund-Browder chart

Q: Lund-Browder chart is the most accurate way of estimating Total Body Surface Area (TBSA) in:

A) Burn
B) Pressure ulcer
C) Insensible loss
D) Vasculopathy
E) Calculation of Cardiac Index (CI)

Answer: A 

Though "Rule of Nines" is the most well known and most widely used method to estimate TBSA in burn patients, the Lund-Browder chart, developed almost 75 years ago, is still the most accurate method for estimating TBSA. It has a particular advantage of being applicable in adults, children as well as infants. Charts are available online with any search engine. Click on the link




Lund CC, Browder NC. The estimation of areas of burns. Surg Gynecol Obstet 1944; 79:352.

Tuesday, July 3, 2018

Motor Activity Assessment Score (MAAS)

Q: Motor Activity Assessment Score (MAAS) is a

A) Post stroke score

B) Sedation score
C) ICU myopathy score
D) Early mobilization score
D) Electromyography (EMG) score

Answer: B

Motor Activity Assessment Score (MAAS) runs from 0 to 6 where 0 is unresponsive and 6 is dangerously  agitated.



Devlin, John W. et al. “Motor Activity Assessment Scale”. Critical Care Medicine 27.7 (1999): 1271-1275.

Monday, July 2, 2018

jugular venous oxygen saturation (SjVO2)

Q: Normal jugular venous oxygen saturation (SjVO2) in patients with Traumatic Brain Injury (TBI) is considered to be approximately at 

A) 80%
B) 70%
C) 60%
D 50%
E) 40%

Answer: C

Jugular venous oximetry is an advanced neuromonitoring technique in TBI patients and it can be obtained with retrograde cannulation of the internal jugular vein. It reflects well with the measurement of oxygen saturation in the blood exiting the brain. Normal  SjVO2 is considered to be approximately at 60 percent. SjVO2 less than 50 percent for mere 10 minutes is considered as an "ischemic desaturation", impaired cerebral perfusion pressure (CPP) and poor outcome.



1. Cruz J. The first decade of continuous monitoring of jugular bulb oxyhemoglobinsaturation: management strategies and clinical outcome. Crit Care Med 1998; 26:344. 

2. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. X. Brain oxygen monitoring and thresholds. J Neurotrauma 2007; 24 Suppl 1:S65.

Sunday, July 1, 2018

Spiked Helmet sign

Q: 'Spiked Helmet' on EKG is due to

A) Hypothermia
B) Acute myocardial infarction (MI)
C) Hypokalemia
D) Repetitive contraction of the diaphragm 
E) prolong QT interval

Answer: D

"The spiked helmet sign is a potential novel ECG marker of a very high risk of impending death, but the prevalence, mechanism, and clinical applicability remain uncertain at this time".

Above statement is referenced from the following article:

"The “Spiked Helmet” Sign: A New Electrocardiographic Marker of Critical Illness and High Risk of Death" 

Citation: Littmann L, Monroe MH. The “Spiked Helmet” Sign: A New Electrocardiographic Marker of Critical Illness and High Risk of Death. Mayo Clinic Proceedings. 2011;86(12):1245-1246. doi:10.4065/mcp.2011.0647

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228627/