Tuesday, April 30, 2019


Q: Wernicke Encephalopathy (WE) is more common in? (select one)

A) Male
B) Female

Answer: B

The paradox of Wernicke encephalopathy (WE)  is that the cases of WE in men outnumbered those in women, but women are more susceptible to acquire WE than men. This is not a true paradox 
after adjusting for alcohol dependence, which is higher in men.



1. Victor, M, Adams, RA, Collins, GH. The Wernicke-Korsakoff syndrome and related disorders due to alcoholism and malnutrition. FA Davis, Philadelphia 1989.

2.  Harper C. The incidence of Wernicke's encephalopathy in Australia--a neuropathological study of 131 cases. J Neurol Neurosurg Psychiatry 1983; 46:593.

Monday, April 29, 2019

thiamine def

Q: Hemodialysis or peritoneal dialysis causes the loss of? (select one)

A) Water soluble vitamins
B) Fat soluble vitamins

Answer: A

Although it may be easy to guess the answer as dialysis serves the purpose of euvolemia, the objective of the above question is to pinpoint the loss of a very important vitamin, Thiamine. There is a misconception that thiamine is only deficient in chronic alcoholism patients. Thiamine is water-soluble and can be deficient in many other situations like anorexia nervosa, hyperemesis of pregnancy, total parental nutrition (TPN) and starvation.




Hung SC, Hung SH, Tarng DC, et al. Thiamine deficiency and unexplained encephalopathy in hemodialysis and peritoneal dialysis patients. Am J Kidney Dis 2001; 38:941. 

Sunday, April 28, 2019

Gallavardin phenomenon

Q: What is Gallavardin phenomenon?

Answer: 95 years ago Dr. Gallavardin reported that murmur of aortic valve stenosis may change its quality and becomes musical at the apex. This can be confused as a murmur of mitral regurgitation. Both murmurs can be differentiated by the fact that the apical murmur of the Gallavardin phenomenon does not radiate to left axilla.




1. Bedford DE (July 1958). "Louis Gallavardin". Br Heart J. 20 (3): 299–301

Saturday, April 27, 2019

FFP in ACE-I induced angio-edema

Q: Fresh Frozen Plasma (FFP) is used to treat Angiotensin-converting enzyme (ACE) inhibitors induced angioedema because it contains? (Select One) 

A) Angiotensin-converting enzyme (ACE)
 B) bradykinin

Answer: A

Fresh frozen plasma contains a subsequent amount of the enzyme ACE, which degrades bradykinin and helps in resolution of angioedema. This is a common knowledge that ACE-I induced angioedema is bradykinin-mediated but very few people understand the actual reason behind using FFP in this condition. It is an effective treatment and may be very valuable during refractory or resistant ACE-I induced angioedema. 




1. Karim MY, Masood A. Fresh-frozen plasma as a treatment for life-threatening ACE-inhibitor angioedema. J Allergy Clin Immunol 2002; 109:370. 

2. Warrier MR, Copilevitz CA, Dykewicz MS, Slavin RG. Fresh frozen plasma in the treatment of resistant angiotensin-converting enzyme inhibitor angioedema. Ann Allergy Asthma Immunol 2004; 92:573. 

3. Hassen GW, Kalantari H, Parraga M, et al. Fresh frozen plasma for progressive and refractory angiotensin-converting enzyme inhibitor-induced angioedema. J Emerg Med 2013; 44:764.

Friday, April 26, 2019


Q: Regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) should be used with caution at least in which one condition?

Answer: Acute liver failure

RCA should be used with high caution whenever there is a suspicion of decrease clearance of citrate. One such commonly encountered situation in ICU is an acute liver failure when transaminases go into thousands. In ICU this is most commonly seen in shock liver. Inability of liver to metabolize citrate results in severe acidosis and a decrease in ionized calcium.




1. Apsner R, Schwarzenhofer M, Derfler K, et al. Impairment of citrate metabolism in acute hepatic failure. Wien Klin Wochenschr 1997; 109:123. 

2. Kramer L, Bauer E, Joukhadar C, et al. Citrate pharmacokinetics and metabolism in cirrhotic and noncirrhotic critically ill patients. Crit Care Med 2003; 31:2450. 

Thursday, April 25, 2019

hypertensive autonomic storm in deceased organ donor

Q: During the management of the deceased organ donor, a hypertensive autonomic storm may become a hurdle due to massive sympathetic discharge following brain death. Which drug can best counteract this effect?

Answer: Esmolol

Usual sequelae following brain death is an initial hypertensive crisis followed by hypotension. This hypertensive crisis and tachycardia are frequently referred to as an autonomic storm. This happens due to massive sympathetic discharge after brain death. Esmolol, a beta-adrenergic antagonist, being a short-acting agent is best to counteract this effect.




1. Kotloff RM, Blosser S, Fulda GJ, et al. Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement. Crit Care Med 2015; 43:1291. 

2. Audibert G, Charpentier C, Seguin-Devaux C, et al. Improvement of donor myocardial function after treatment of autonomic storm during brain death. Transplantation 2006; 82:1031. 

3. Ferrera R, Hadour G, Tamion F, et al. Brain death provokes very acute alteration in myocardial morphology detected by echocardiography: preventive effect of beta-blockers. Transpl Int 2011; 24:300.

Wednesday, April 24, 2019


Q: Anti-hypertensive drug methyldopa is prone to cause? (select one)

A) Sinus Tachycardia
B) Sinus Bradycardia

Answer: B

Being sympatholytic drug methyldopa tends to cause sinus bradycardia. Clinically this may become significant if other sympatholytic drugs i.e beta blockers or clonidine are used concomitantly. Moreover, methyldopa can cause directly sinus node dysfunction resulting in sinus bradycardia.



1. van Zwieten PA, Thoolen MJ, Timmermans PB. The hypotensive activity and side effects of methyldopa, clonidine, and guanfacine. Hypertension. 1984 Sep-Oct;6(5 Pt 2):II28-33. 

2. Jesse C. Davis, MD; James A. Reiffel, MD; J. Thomas Bigger Jr, MD Sinus Node Dysfunction Caused by Methyldopa and Digoxin JAMA. 1981;245(12):1241-1243.

Tuesday, April 23, 2019

neostigmine in colonic pseudo-obstruction

Q: 67 year old male is admitted to ICU with acute colonic pseudo-obstruction and cecal diameter >11 cm. There was no resolution of symptoms with all conservative treatment. Decision was made to use Neostigmine. Which one trick may help to reduce the side effect of bradycardia and bronchoconstriction?

Answer:  Coadministration of glycopyrrolate

 Neostigmine  can be used to relieve acute colonic pseudo-obstruction when conservative treatments remain ineffective. The usual dose is 2 mg IV given over 5 minutes. Being an acetylcholinesterase inhibitor, neostigmine carries the risk of causing bradycardia and bronchoconstriction. Coadministration of glycopyrrolate, which is an anticholinergic agent and may have some activity on the muscarinic receptors of the colon, may help to reduce these side effects.




Korsten MA, Rosman AS, Ng A, et al. Infusion of neostigmine-glycopyrrolate for bowel evacuation in persons with spinal cord injury. Am J Gastroenterol 2005; 100:1560.

Monday, April 22, 2019

End of life eye care

Q: What is the reason for the inability to close the eyes of terminally ill patients who are chronically sick?

Answer: Cachexia 

 The objective of the above question is to emphasize the importance of the passionate care of terminally ill patients. Cachexia causes the loss of retroorbital fat pad, and the orbit falls too posterior in its socket. This leads to constant exposure of conjunctiva even when the patient is sleeping or sedated. Damage can be prevented with the use of ophthalmic lubricants or artificial tears.



Further readings: 

1. Bailey FA, Burgio KL, Woodby LL, et al. Improving processes of hospital care during the last hours of life. Arch Intern Med 2005; 165:1722. 

2. Plonk WM Jr, Arnold RM. Terminal care: the last weeks of life. J Palliat Med 2005; 8:1042.

3. Pantilat SZ. End-of-life care for the hospitalized patient. Med Clin North Am 2002; 86:749.

Sunday, April 21, 2019


Q: All of the followings are the antecedent signs & symptoms of Eclampsia except?

A) Hypertension 
B) Headache 
C) Visual disturbances 
D) Ankle clonus
E) Left upper quadrant pain 

Answer: E

About 3/4th of the patients with eclampsia have some antecedent signs and symptoms developing in the hours prior to the initial seizure. Hypertension is the most common sign followed by a headache. Although visual disturbances have been classically described only a quarter of the women developed this. Ankle clonus is also reported.

It's a right upper quadrant or epigastric pain which is common, proposed to be due to stretching of the liver capsule.




1. Berhan Y, Berhan A. Should magnesium sulfate be administered to women with mild pre-eclampsia? A systematic review of published reports on eclampsia. J Obstet Gynaecol Res 2015; 41:831. 

2. Chuan FS, Charles BG, Boyle RK, Rasiah RL. Population pharmacokinetics of magnesium in preeclampsia. Am J Obstet Gynecol 2001; 185:593.

Saturday, April 20, 2019

Delta P on ECMO

Q: What does Delta P on ECMO's every day monitoring signifies?

Answer: The difference between the pressures on pre and post membrane outlets provides the transmembrane pressure gradient. An increase in the trans-membrane pressure gradient indicates clot formation within the oxygenator. The trans-membrane pressure gradient should stay less than 50 mm Hg. If high, it requires proper anti-coagulation or may be the replacement of oxygenator.



1. Adult Extra Corporeal membrane Oxygenation (ECMO); Policy & Guideline. RPAH 2010 

2. Extra Corporeal Membrane Oxygenation (ECMO) in the Intensive Care Unit. St Vincent’s Hospital Sydney ICU 2010 3. Marasco, S.F., Lukas, G., McDonald, M., McMillan, J., & Ihle, B. (2008).

3.Review of ECMO (Extra Corporeal Membrane Oxygenation) support in critically ill adult patients. Heart, Lung and Circulation, 17S: S41-S47.

Friday, April 19, 2019

HBV in pregnancy

Q: Acute Hepatitis B Virus (HBV) has the highest rate of transmission? (select one)

A) early in the pregnancy
B) near the time of delivery

Answer: B

This piece of maternal hepatology is extremely important to know as an active intervention is required if HBV occurs near the time of delivery.

Transmission to the fetus may be as low as 10 percent in the early part of the pregnancy but may go up to 60 percent at the time of delivery. Hepatitis panel should be followed closely. If hepatitis B surface antigen (HBsAg) stays positive or has detectable serum HBV DNA near the delivery, baby should receive hepatitis B immune globulin and the 1st dose of the hepatitis B vaccine within 12 hours of birth. Ideally, a hepatologist should be consulted.



1. Sookoian S. Liver disease during pregnancy: acute viral hepatitis. Ann Hepatol 2006; 5:231. 

 2. Jonas MM. Hepatitis B and pregnancy: an underestimated issue. Liver Int 2009; 29 Suppl 1:133.

Thursday, April 18, 2019

PG toxicity

Q: Continuous intravenous (IV) lorazepam is frequently used in ICU. Propylene glycol (PG) is the carrier to administer IV lorazepam drip. Prolong use of IV lorazepam may cause propylene glycol toxicity. Which one test could predict and correlate directly with PG toxicity?

Answer:  Osmolal gap 

 Propylene glycol toxicity may occur with prolong administration of lorazepam or diazepam. It can cause significant skin and soft tissue necrosis in case of extravasation, arrhythmia, hemodynamic instability, lactic acidosis, seizure, coma, and eventually multi-system organ failure (MSOF). Propylene glycol causes hyperosmolarity and an anion gap metabolic acidosis. In case of any suspicion, osmolal gap correlates with PG concentrations and can be a reliable surrogate marker of PG toxicity. Treatment is to discontinue the infusion and, if life-threatening, emergent hemodialysis should be instituted. 



1. Wilson KC, Reardon C, Theodore AC, Farber HW. Propylene glycol toxicity: a severe iatrogenic illness in ICU patients receiving IV benzodiazepines: a case series and prospective, observational pilot study. Chest 2005; 128:1674. 

2. Barnes BJ, Gerst C, Smith JR, et al. Osmol gap as a surrogate marker for serum propylene glycol concentrations in patients receiving lorazepam for sedation. Pharmacotherapy 2006; 26:23. 

Wednesday, April 17, 2019

AP in pregnancy

Q: 24 year female at 34 weeks of pregnancy is admitted to ICU with exacerbation of asthma which is getting better. Routine labs showed three times higher than normal value of Serum alkaline phosphatase (AP). All other lab values are in normal range. What should be your next step?

A) STAT ultrasound of the liver
B) Emergent delivery of the baby
C) Check for HELLP syndrome
D) No intervention at this time
E) Check Hepatitis panel

Answer: D

Pregnancy may affect liver function test, particularly serum alkaline phosphatase. Total serum AP goes up to 3-4 times higher than normal, particularly in the third trimester. This is due to placental alkaline phosphatase. The best approach is to look at serum gamma-glutamyl transpeptidase (GGTP) level, which usually gets lower in pregnancy. This may help to confirm placental source of AP. In the absence of no other findings, there is no reason to go behind a million dollar workup.

Ultrasound of liver can be considered but there is no need for STAT order (choice A)

Patient's clinical situation is improving. Until and unless there is no harm anticipated to baby, there is no need to rush for delivery (choice B)

With normal platelet count and other LFTs in normal range, it is unlikely to be HELLP syndrome (choice C).

With no abnormality in AST, ALT, and bilirubin, hepatitis is very unlikely (choice E)



Bacq Y, Zarka O, Bréchot JF, et al. Liver function tests in normal pregnancy: a prospective study of 103 pregnant women and 103 matched controls. Hepatology 1996; 23:1030.

Tuesday, April 16, 2019

Secondary PPH

Q: Secondary postpartum hemorrhage (PPH) is defined as any significant uterine bleeding occurring after?

A) 24 hours postpartum
B) 48 hours postpartum
C) 72 hours postpartum
D) one week postpartum
E) it is not defined by time

Answer: A

Primary and secondary PPH is defined by the cutoff of a time period and is also limited by a time period. i.e., Secondary PPH is generally defined as any significant uterine bleeding between 24 hours and 12 weeks postpartum. This cutoff is set as management may become different for primary and secondary PPH.



1. Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol 2017; 130:e168. 

2. Dossou M, Debost-Legrand A, Déchelotte P, et al. Severe secondary postpartum hemorrhage: a historical cohort. Birth 2015; 42:149.

Monday, April 15, 2019

Left Main Equivalent Disease

Q: What is Left main equivalent disease? 

Answer:  Although left main coronary artery disease (LMCAD) is a well-known disease, and a subject of frequent discussions, unfortunately, less attention gets paid to Left main equivalent disease, which is equally dreaded in morbidity and mortality.  Left main equivalent disease is defined as a combination of severe i.e. > 70 % stenosis of proximal left anterior descending (LAD) coronary artery and proximal left circumflex disease. It signifies a poor prognosis. Coronary artery bypass graft surgery (CABG) is associated with improved survival.



1. Chaitman BR, Davis K, Fisher LD, et al. A life table and Cox regression analysis of patients with combined proximal left anterior descending and proximal left circumflex coronary artery disease: non-left main equivalent lesions (CASS). Circulation 1983; 68:1163. 

2. Caracciolo EA, Davis KB, Sopko G, et al. Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease. Long-term CASS experience. Circulation 1995; 91:2335.

Sunday, April 14, 2019

IVF in acute pancreatitis

Q: Which of the following intravenous fluid (IVF) preferred in acute pancreatitis?

A) Normal Saline (NS)
B) Lactate Ringer's (LR)

Answer: B

The three pillars of management of acute pancreatitis are
  • fluid resuscitation 
  • pain control
  • nutritional support 
IVF take precedence over everything as it has clearly shown that early and proper (considering renal failure and congestive heart failure) IVF resuscitation decreases analgesic requirement, increases enteral tolerance and decreases morbidity and mortality.

Although evidence is not very strong it favors LR as a preferred agent if there is no renal insuff., hypercalcemia or hyperkalemia. LR has shown to lower mean C-reactive protein (CRP) level and reduction in systemic inflammatory response syndrome (SIRS).



1. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13:e1. 

 2. Wu BU, Hwang JQ, Gardner TH, et al. Lactated Ringer's solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011; 9:710. 

3. Trikudanathan G, Navaneethan U, Vege SS. Current controversies in fluid resuscitation in acute pancreatitis: a systematic review. Pancreas 2012; 41:827. 

4. Gardner TB, Vege SS, Chari ST, et al. Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in-hospital mortality. Pancreatology 2009; 9:770.

Saturday, April 13, 2019

IV contrast in sickle cell

Q: Intravenous iodinated contrast can induce sickle crisis in patients with sickle cell disease? (select one)

A) True
B) False

Answer:  B

It has been speculated in the past that IV iodinated contrast is not safe for sickle cell patients but this fear is proved to be unfounded. This was postulated that IV iodinated contrast contrast because of their high osmolality may cause osmotic shrinkage of red blood cells, and may precipitate a sickle cell crisis. Studies have shown that clinically this is not significant and risk is equivalent to general population if renal function is normal.



1. Morcos SK. Review article: Acute serious and fatal reactions to contrast media: our current understanding. Br J Radiol 2005; 78:686. 

2. Kimberly L. et.al. Safety of Iodinated Intravenous Contrast Medium Administration in Sickle Cell Disease - The American Journal of Medicine Volume 125, Issue 1, January 2012, Pages 100.e11-100.e16

Friday, April 12, 2019

HBO any myopia

Q: Myopia from hyperbaric oxygen (HBO) is? (select one) 

 A) Reversible 
B) Irreversible

Answer: A

Modality of hyperbaric oxygen is frequently used as an adjuvant therapy in different variety of patients and it is not uncommon for an ICU physician to encounter it. But it comes with it's  own price. Some of the common complications are middle ear barotrauma, sinus barotrauma, myopia, pulmonary barotrauma, seizure and decompression sickness. 

 Most of these side effects are reversible including myopia.



Camporesi EM, Bosco G. Mechanisms of action of hyperbaric oxygen therapy. Undersea Hyperb Med 2014; 41:247.

Thursday, April 11, 2019


Q: During continuous renal replacement therapy (CRRT) what's the best way to assesses that the excessive citrate is given and regional citrate anticoagulation (RCA) may need to be stopped?

Answer: A ratio of total calcium to ionized calcium >2.5

Other ways to suspect excessive citrate during CRRT were worsening metabolic acidosis, increasing anion gap, decreasing ionized calcium or higher requirement of calcium infusion rates.



1. Meier-Kriesche HU, Gitomer J, Finkel K, DuBose T. Increased total to ionized calcium ratio during continuous venovenous hemodialysis with regional citrate anticoagulation. Crit Care Med 2001; 29:748. 

2. Bakker AJ, Boerma EC, Keidel H, et al. Detection of citrate overdose in critically ill patients on citrate-anticoagulated venovenous haemofiltration: use of ionised and total/ionised calcium. Clin Chem Lab Med 2006; 44:962.

Wednesday, April 10, 2019

vasoreactive test in PH

Q: All of the following can be used for vasoreactivity test in pulmonary hypertension except? 

 A) inhaled nitric oxide 
B) epoprostenol 
C) adenosine 
D) inhaled iloprost 
 E) sildenafil

Answer: E

Many times vasoreactive test in pulmonary hypertension is carried out in ICU setting as it requires close hemodynamic monitoring and right heart catheterization. Vasoreactivity test helps in determining the right agent for treatment. Drugs commonly used for vasoreactivity testing include inhaled nitric oxide, epoprostenol, adenosine, and inhaled iloprost. Sildenafil is not appropriate for this purpose.



Badesch DB, Abman SH, Ahearn GS, et al. Medical therapy for pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest 2004; 126:35S.

Tuesday, April 9, 2019

Procalcitonin in VAP

Q: Procalcitonin has it's utility in Ventilator-Associated Pneumonia (VAP) for?  (select one)

A) Initiation of antibiotics 
B) Discontinuation of antibiotics


Unlike the utility of procalcitonin in making a decision for antibiotics initiation in suspected community-acquired pneumonia (CAP), it has practically no role in the initiation of antibiotics in VAP.1 But it certainly helps in determining when to stop antibiotics 2, as well as to act as a prognostic marker. 3, 4



1. Luyt CE, Combes A, Reynaud C, et al. Usefulness of procalcitonin for the diagnosis of ventilator-associated pneumonia. Intensive Care Med 2008; 34:1434.

2. Stolz D, Smyrnios N, Eggimann P, et al. Procalcitonin for reduced antibiotic exposure in ventilator-associated pneumonia: a randomised study. Eur Respir J 2009; 34:1364.

3. Luyt CE, Guérin V, Combes A, et al. Procalcitonin kinetics as a prognostic marker of ventilator-associated pneumonia. Am J Respir Crit Care Med 2005; 171:48.

4. Hillas G, Vassilakopoulos T, Plantza P, et al. C-reactive protein and procalcitonin as predictors of survival and septic shock in ventilator-associated pneumonia. Eur Respir J 2010; 35:805.

Monday, April 8, 2019

tPA and clot location

Q: During reperfusion therapy for acute ischemic stroke (CVA) which clots are more resistant to thrombolysis? (select one) 

 A)  proximal in the cerebrovascular arterial tree 
 B) distal in the cerebrovascular arterial tree


In acute CVA proximal sites of occlusion in the cerebrovascular arterial tree are more resistant to thrombolysis i.e. a clot in an internal carotid artery (ICA) is expected to be more resistant than middle cerebral artery (MCA). This is due to the fact that clots more proximal in CV arterial-tree tend to be bigger in size. Moreover, they may be promoting adjacent thrombosis, resulting in a very long thrombus. Another contributing factor is the relative lack of fibrin in large vessels in situ thromboses in comparison to cardiac origin fibrin-rich embolic thromboses.




1.  Linfante I, Llinas RH, Selim M, et al. Clinical and vascular outcome in internal carotid artery versus middle cerebral artery occlusions after intravenous tissue plasminogen activator. Stroke 2002; 33:2066. 

2. Saqqur M, Uchino K, Demchuk AM, et al. Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke 2007; 38:948. 

3. Molina CA, Montaner J, Arenillas JF, et al. Differential pattern of tissue plasminogen activator-induced proximal middle cerebral artery recanalization among stroke subtypes. Stroke 2004; 35:486.

Sunday, April 7, 2019

pleural N-terminal pro-BNP in CHF

Q; What is the utility of measuring pleural N-terminal pro-BNP?

Answer: Excessive diuresis in congestive heart failure (CHF) may make pleural effusion looks exudative. Pleural fluid NT-proBNP has a high degree of correlation in CHF and may have a utility in such situations. 5



1. Porcel JM. Utilization of B-type natriuretic peptide and NT-proBNP in the diagnosis of pleural effusions due to heart failure. Curr Opin Pulm Med 2011; 17:215. 

2. Kolditz M, Halank M, Schiemanck CS, et al. High diagnostic accuracy of NT-proBNP for cardiac origin of pleural effusions. Eur Respir J 2006; 28:144. 

3. Tomcsányi J, Nagy E, Somlói M, et al. NT-brain natriuretic peptide levels in pleural fluid distinguish between pleural transudates and exudates. Eur J Heart Fail 2004; 6:753. 

4. Porcel JM, Martínez-Alonso M, Cao G, et al. Biomarkers of heart failure in pleural fluid. Chest 2009; 136:671. 

5. Porcel JM, Chorda J, Cao G, et al. Comparing serum and pleural fluid pro-brain natriuretic peptide (NT-proBNP) levels with pleural-to-serum albumin gradient for the identification of cardiac effusions misclassified by Light's criteria. Respirology 2007; 12:654. 

Saturday, April 6, 2019

ABCDE of trauma

Q: Describe the "ABCDE" bundle in the primary survey of a trauma patient?

Answer: For the ease of the care of trauma patients, a simple mnemonic is developed for the primary assessment of trauma patients:
  • Airway - includes cervical spine stabilization 
  • Breathing - equivalent to adequate oxygenation 
  • Circulation - includes bleeding control with goal to maintain adequate end-organ perfusion
  • Disability assessment - includes basic neurologic evaluation 
  • Exposure - it also suggests undressing the patients, searching everywhere for possible injury, and preventing hypothermia



American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 9th ed, American College of Surgeons, Chicago 2012.

Friday, April 5, 2019

Glucose level in malaria

Q: Which of the following is the sign of poor prognosis in severe malaria? (select one)

A) Hyperglycemia
B) Hypoglycemia

Answer: B

Hypoglycemia is not uncommon in malaria and may be an indicator of poor outcome. It occurs due to  decrease hepatic gluconeogenesis, depletion of hepatic glycogen stores, and increase consumption of glucose. Another very interesting cause of hypoglycemia in severe malaria is Quinine-induced hyperinsulinemia.



Gilbert N Ogetii, Samuel Akech, Julie Jemutai, Mwanamvua Boga, Esther Kivaya, Greg Fegan and Kathryn Maitland -  Hypoglycaemia in severe malaria, clinical associations and relationship to quinine dosage BMC Infectious Diseases 2010 10:334

Thursday, April 4, 2019


Q: Which of the following has shown favorable outcome towards mortality in Acute Respiratory Distress Syndrome (ARDS)?

A) cisatracurium 
B) vecuronium
C) succinylcholine
D) rocuronium 
E) Use of no Neuro-Muscular Blockade (NMB)

 Answer: A

NMB are not very desirable for use in ICUs but in some situations they become life savers like severe ARDS. Interestingly, they have shown some favorable tendency in decreasing mortality in these patients.

In 2010 trial of 340 patients, group treated with cisatracurium had more ventilator-free days in first 90 days, less barotrauman but more importantly no difference in the ICU-acquired neuromuscular weakness. Another meta-analysis of five trials also reported improved mortality.



Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 2010; 363:1107. 

Tao W, Yang LQ, Gao J, Shao J. Neuromuscular blocking agents for adult patients with acute respiratory distress syndrome: A meta-analysis of randomized controlled trials. J Trauma Acute Care Surg 2018; 85:1102.

Wednesday, April 3, 2019

TCA overdose

Q: Tricyclic antidepressant (TCAs) toxicity can cause? (select one) 

A) cholinergic effects 
B) anticholinergic effects 


 TCAs have anticholinergic effects and so the poisoning can cause hyperthermia, flushing, mydriasis that responds poorly to light, delirium, intestinal ileus, and urinary retention.



Lynch R. Tricyclic antidepressant overdose. Emerg Med J 2002; 19:596.

Glauser J. Tricyclic antidepressant poisoning. Cleve Clin J Med 2000; 67:704.

Tuesday, April 2, 2019

Nutrition in ICU

Q: Which of the following is the preferred source of energy in critically ill patients? 

A) carbohydrates 
 B) fat (lipid) 
C) protein 
D) normal saline (0.9 NS) 
E) minerals 

 Answer: A

Lipid mobilization is impaired in critically ill patients and carbohydrates are the preferred source of energy during this time. Although the prescribed nutrition should be balanced and protein should be added to avoid negative nitrogen balance, as well as to utilize it as a substrate for gluconeogenesis.



Nordenström J, Carpentier YA, Askanazi J, et al. Free fatty acid mobilization and oxidation during total parenteral nutrition in trauma and infection. Ann Surg 1983; 198:725. 

Plank LD, Connolly AB, Hill GL. Sequential changes in the metabolic response in severely septic patients during the first 23 days after the onset of peritonitis. Ann Surg 1998; 228:146.

Monday, April 1, 2019

ETT bending

Q: During intubation, an endotracheal tube (ETT) should be bent no more than?

A) 20 degrees
B) 35 degrees
C) 45 degrees
D) 60 degrees
E) 90 degrees ("hockey stick" conformation)

Answer: B

This is a common practice of some senior residents to teach junior residents to put ETT at "hockey stick" conformation if difficult intubation is anticipated. This should be done only and only in very experienced hands. Ideally, ETT should never be bent > 35 degrees. Beyond that, more acute angles may cause the ETT to get stuck on the anterior trachea, prevent advancement and injured trachea.



Levitan RM, Pisaturo JT, Kinkle WC, et al. Stylet bend angles and tracheal tube passage using a straight-to-cuff shape. Acad Emerg Med 2006; 13:1255.