Tuesday, June 30, 2020

tendon reflex exam

Q: Brachioradialis tendon reflex should be tested? (select one) 

A) 5 cm above the wrist 
B) 10 cm above the wrist

Answer: B

Tendon reflexes are an integral part of neurological exam. There are five places where tendon reflexes are checked. Biceps, triceps, brachioradialis, knee (patellar), and ankle (Achilles). For proper tendon reflex exam the joint should be at about 90 degrees and fully relaxed, and the head of the hammer drop like a pendulum so that it strikes the tendon. For brachioradialis tendon reflex, cradle the wrist joint in your own arm to support it, and with your other arm use the hammer. Hammer should be dropped about 10 cm above the wrist on the radial aspect of the forearm for proper response.




Gelb, DJ. The Neurologic Examination. In: Introduction to clinical neurology. Butterworth Heinemann, Woburn, MA 2000.

Monday, June 29, 2020

Predicted normal body

Q: In LOW TIDAL VOLUME VENTILATION (LTVV) for patients with ARDS, tidal volume (TV) should be adjusted according to? (select one)

A) Ideal body weight
B) Predicted body weight

Answer:  B

There is a difference between ideal body weight and the predicted body weight.

 Ideal body weight (IBW) is simply the weight for a given height. Although it takes into account male and female genders but easy to look into through a simple chart. This is just a generalization that persons of the same height should have the same mass. This may create huge errors in standardising individual treatments.

 Predicted normal body weight (PBW) represents the expected normal weight of an obese individual as the sum of their lean body mass and their predicted normal fat mass, which excludes excess fat mass. This is a more reliable weight in standardising individual treatments. The formula for predicted body weight are

  • For females: PBW (kg) = 45.5 + 0.91 * (height [cm] - 152.4) 
  • For males: PBW (kg) = 50 + 0.91 * (height [cm] - 152.4)



1. NHLBI ARDS Network. Available at: http://www.ardsnet.org/

2. JJ MacDonald , J Moore , V Davey , S Pickering and T Dunne. The weight debate. Journal of the Intensive Care Society 2015, Vol. 16(3) 234–238 

Sunday, June 28, 2020

Acute DIC and organ damage

Q: Which of the following organ is most vulnerable during an episode of acute Disseminated intravascular coagulation (DIC)?

A) Kidney
B) Liver
C) Lungs
D) Brain
E) Adrenals

Answer: A

In real-world there is no organ that is immune from acute DIC, but renal function tends to get the most damage. About 40-50 percent of patients develop some sort of renal failure. It is followed by the liver. Pulmonary damage is mostly manifested by hemoptysis, and underlying microthrombi eventually leading to acute respiratory distress syndrome (ARDS). Neurologic complications may occur as well. Adrenals require close watch as Waterhouse-Friderichsen syndrome may occur due to adrenal hemorrhage or infarction.



1. Ohashi R, Hosokawa Y, Kimura G, Kondo Y, Tanaka K, Tsuchiya S. Acute renal failure as the presenting sign of disseminated intravascular coagulation in a patient with metastatic prostate cancer. Int J Nephrol Renovasc Dis. 2013;6:47-51. doi:10.2147/IJNRD.S41813 

2.  Dominic SC; Somiah S; Srinivas; Sheeba SD; Swapna Acute renal failure in disseminated intravascular coagulation. Indian Journal of Nephrology. 1995 Apr-Jun; 5(2): 47-9 

3. Siegal T, Seligsohn U, Aghai E, Modan M. Clinical and laboratory aspects of disseminated intravascular coagulation (DIC): a study of 118 cases. Thromb Haemost 1978; 39:122.

Saturday, June 27, 2020


Q: By definition, thrombocytosis is platelet count more than? (select one)

A) >350,000/microL
B) >450,000/microL

Answer: B

By definition, normal platelet count - both in adults and pediatric population - is 150,000 to 450,000/microL. Any count above 450,000/microL is described as thrombocytosis. 

Broadly they are divided into two classes according to it causes 

1. Reactive which is due to anemia, infections, inflammation, drug-induced, trauma, or asplenia 

2. Autonomous which is also known as primary thrombocytosis which is due to any pathology in mechanisms that lay within the megakaryocyte or its precursor cells. Two major causes in this class besides mutations are hematologic malignancies and familial thrombocytosis.



1. Bleeker JS, Hogan WJ. Thrombocytosis: diagnostic evaluation, thrombotic risk stratification, and risk-based management strategies. Thrombosis. 2011;2011:536062. doi:10.1155/2011/536062 

2. Skoda RC. Thrombocytosis. Hematology. 2009:159–167.

Friday, June 26, 2020

pulse-ox probe and MRI

Q: Why pulse-oximetry probes should be temporarily removed while patient is in an MRI?

Answer: Pulse oximeter cables, which act as an antenna may generate electrical skin currents, and results in a full-thickness burn. Unfortunately, this episode occurs very quickly even before the patient feels it. 

Click the link on Reference # 1 to see the pictures of such MRI induced burns.




1. Sung SJ, Park YS, Cho JY. Full Thickness Burn on the Finger due to Pulse Oximetry during Magnetic Resonance Imaging in a Conscious Patient. Arch Plast Surg. 2016;43(6):612‐613. doi:10.5999/aps.2016.43.6.612. Weblink: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5122558/ (last accessed June 4, 2020)

2. Karoo RO, Whitaker IS, Garrido A, et al. Full-thickness burns following magnetic resonance imaging: a discussion of the dangers and safety suggestions. Plast Reconstr Surg. 2004;114:1344–1345

3. Dempsey MF, Condon B. Thermal injuries associated with MRI. Clin Radiol 2001; 56:457.

Thursday, June 25, 2020

Amylase Lipase in pancreatic trauma

Q: During trauma, pancreatic injury should quickly be ruled out by elevated amylase/lipase? (select one) 

A) True 
B) False

Answer: B

Serum amylase or lipase has no role in acute pancreatic injury in trauma. In fact, elevated amylase or lipase can be present in abdominal trauma even when the pancreas is not involved. Only reliable method is either via CT scan or exploratory laparotomy.



1. Takishima T, Sugimoto K, Hirata M, et al. Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations. Ann Surg 1997; 226:70. 

2. Buechter KJ, Arnold M, Steele B, et al. The use of serum amylase and lipase in evaluating and managing blunt abdominal trauma. Am Surg 1990; 56:204.

Wednesday, June 24, 2020

urgent start PD

Q: Urgent-start peritoneal dialysis is associated with worse outcomes than urgent-start hemodialysis?

A) True
B) False

Answer: B

The objective of the above question is to highlight the difference between emergent and urgent-start dialysis. 

Emergent hemodialysis is required for hyperkalemia, volume overload, or marked uremia. 

Urgent-start dialysis is the need for dialysis in newly diagnosed end-stage renal disease (ESRD) patients. Urgent-start peritoneal dialysis is a very useful alternative since more than half of all new dialysis patients do not have a dialysis plan. Outcomes in urgent-start peritoneal dialysis are as good as urgent-start hemodialysis with no difference in overall mortality. Actually, urgent-start hemodialysis is found to have a higher incidence of bacteremia.




1. Jin H, Fang W, Zhu M, et al. Urgent-Start Peritoneal Dialysis and Hemodialysis in ESRD Patients: Complications and Outcomes. PLoS One 2016; 11:e0166181. 

2. Koch M, Kohnle M, Trapp R, et al. Comparable outcome of acute unplanned peritoneal dialysis and haemodialysis. Nephrol Dial Transplant 2012; 27:375.

Tuesday, June 23, 2020

hypokalemic paralysis

Q: Muscle weakness in hypokalemia usually starts developing from? (select one)

A) upper body
B) lower body

 Answer:  B

Muscle weakness in hypokalemia usually occurs when potassium level goes below above 2.5 meq/L. unless there is an acute drop. Muscle weakness usually begins with the lower extremities, progresses to the trunk, and later involves upper extremities before preceding to paralysis.




Ahlawat SK, Sachdev A. Hypokalaemic paralysisPostgraduate Medical Journal 1999;75:193-197.

Monday, June 22, 2020

Remdesivir and liver

Q: Remdesivir should be discontinued if Liver Funtion Test (LFT) is? 

A) >2 times of normal 
B) >5 times of normal 


 Remdesivir is in use for COVID-19 patients with severe disease. It should be avoided in patients with an estimated glomerular filtration rate (eGFR) less than 30 mL/min per 1.73 m2. Remdesivir also carries the risk of liver failure. Per existing guidelines, remdesivir is not recommended if alanine aminotransferase ≥5 times the upper limit of normal, and/or should be discontinued if it rises above this level during treatment and/or if there is any sign of acute liver failure.



 Boettler T, Newsome PN, Mondelli MU, Maticic M, Cordero E, Cornberg M,Berg T, Care of patients with liver disease during the COVID-19 pandemic: EASL-ESCMID position paper, JHEP Reports (2020), 
doi: https://doi.org/10.1016/j.jhepr.2020.100113 

Sunday, June 21, 2020

total pain

Q: What are the frameworks of 'total pain'  and 'pathological grieving' at the end of life care?

Answer:  Dame Cicely Saunders, an English nurse is considered as the founder of modern hospice. She is known for introducing two major frameworks in palliative care. 

One is "total pain." This is pertinent to patients. It refers to the complex mechanisms and manifestations of suffering, including its physical, emotional, socioeconomic, and spiritual components. 

Second is "pathological grieving", after her three loved ones including her father died in a very short period of time. This is pertinent to patients' friends and family. It refers to the disabling grieving after a loved one's death and may require intervention.

#palliative care


1. Saunders C. The depths and the possible heights. Medical News July 10, 1964. p.16.

2. Gort G. Pathological grief: causes, recognition, and treatment. Can Fam Physician. 1984;30:914‐924.

Saturday, June 20, 2020

Physical restraints

Q: Physical restraints in delirious patients decrease overall mortality by decreasing self-harm? (select one)

A) True
B) False


This question's objective is to highlight the dangers of physical restraints, which are still frequently used in in-patient settings, including ICUs. 

Physical restraints should be used ONLY ONLY ONLY as a last resort - and AS BRIEFLY AS POSSIBLE.

Not only this inhuman mode increase agitation, loss of mobility, pressure ulcers, and aspiration, but it also increases the odds of persistent delirium at hospital discharge by three folds.



Inouye SK, Zhang Y, Jones RN, et al. Risk factors for delirium at discharge: development and validation of a predictive model. Arch Intern Med 2007; 167:1406.

Friday, June 19, 2020

sodium phosphate enema

Q: Constipation and ileus is a frequent issue in ICU. What are the dangers of using sodium phosphate enemas in elderly patients?

Sodium phosphate enema is usually well tolerated in most patients. But it may cause complications in elderly patients, particularly above the age of 80. It may cause hypotension, volume depletion, hyperphosphatemia, hypo- or hyperkalemia, metabolic acidosis, severe hypocalcemia, renal failure, and prolonged QT interval.



1. Ori Y, Rozen-Zvi B, Chagnac A, et al. Fatalities and severe metabolic disorders associated with the use of sodium phosphate enemas: a single center's experience. Arch Intern Med 2012; 172:263. 

2. Mendoza J, Legido J, Rubio S, Gisbert JP. Systematic review: the adverse effects of sodium phosphate enema. Aliment Pharmacol Ther 2007; 26:9.

Thursday, June 18, 2020

Anbx in sepsis

Q: In patients with septic shock antibiotics should be started at? (select one)

A) full "high-end" loading dose 
B) full "low-end" loading dose

Answer: A

In patients with septic shock, antibiotics should be started at a full "high-end" loading dose if there is no significant contra-indication. This is due to the reason that these patients usually have a increased volume of distribution that occurs due to the administration of intravenous fluid (IVF) resuscitation. Higher clinical success rates are reported with higher peak concentrations of different antibiotics in these patients.




1. Pletz MW, Bloos F, Burkhardt O, et al. Pharmacokinetics of moxifloxacin in patients with severe sepsis or septic shock. Intensive Care Med 2010; 36:979. 

2. van Zanten AR, Polderman KH, van Geijlswijk IM, et al. Ciprofloxacin pharmacokinetics in critically ill patients: a prospective cohort study. J Crit Care 2008; 23:422. 

3. Blot S, Koulenti D, Akova M, et al. Does contemporary vancomycin dosing achieve therapeutic targets in a heterogeneous clinical cohort of critically ill patients? Data from the multinational DALI study. Crit Care 2014; 18:R99. 

4. Zelenitsky S, Rubinstein E, Ariano R, et al. Vancomycin pharmacodynamics and survival in patients with methicillin-resistant Staphylococcus aureus-associated septic shock. Int J Antimicrob Agents 2013; 41:255. 

5. Preston SL, Drusano GL, Berman AL, et al. Pharmacodynamics of levofloxacin: a new paradigm for early clinical trials. JAMA 1998; 279:125. 

6. Kashuba AD, Nafziger AN, Drusano GL, Bertino JS Jr. Optimizing aminoglycoside therapy for nosocomial pneumonia caused by gram-negative bacteria. Antimicrob Agents Chemother 1999; 43:623.

Tuesday, June 16, 2020

Epistaxis in hereditary hemorrhagic telangiectasia

Case: 22 year old female with a past medical history of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) is in ICU with urosepsis and vasodilatory shock. She developed epistaxis on the third day of the admission. Your next line of management? (select one)

A) Observe with nasal packing as it usually subsides spontaneously
B) Call ENT service as it may be a serious issue

 Answer: B

Epistaxis is the most common presenting symptom among younger patients with hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease. Bleeding in these patients can be hard to control. In the setting of high risks like sepsis and DIC, it would be prudent to get ENT service early in the course. The paradox of treatment in these patients may take bedside clinicians by surprise as the friable lesions may appear to bleed more with treatment than without! and expert opinion may be needed.

Epistaxis can be provoked by a variety of factors, besides acute sicknesses. It includes changes in external temperature, humidity, activity, change in diet, insertion of nasogastric tubes, and posture. Gushing bleed is usually a sign of life-threatening arterial bleed.




1. Shah RK, Dhingra JK, Shapshay SM. Hereditary hemorrhagic telangiectasia: a review of 76 cases. Laryngoscope 2002; 112:767.

2. Fuchizaki U, Miyamori H, Kitagawa S, et al. Hereditary haemorrhagic telangiectasia (Rendu-Osler-Weber disease). Lancet 2003; 362:1490.

3. Hoag JB, Terry P, Mitchell S, et al. An epistaxis severity score for hereditary hemorrhagic telangiectasia. Laryngoscope 2010; 120:838.

Monday, June 15, 2020


Q: Which of the following major inflammatory molecule does not get removed via hemadsorption? 

A) interleukin-6 
B) interleukin-10

Answer: B

Hemadsorption is actually hemoperfusion through sorbent-containing cartridges, a process alike continuous renal replacement therapy (CRRT). Hemadsorption provides a larger surface area to enhance the removal of cytokines and inflammatory molecules involved during cytokine storm. This leads to its applicability and popularity in COVID-19 treatment. The most widely available commercial sorbent is CytoSorb which has porous polymer beads. The data is still experimental. Unfortunately, though this process theoretically sounds effective it does not remove two major inflammatory molecules, endotoxin and interleukin-10.




1. Honore PM, Jacobs R, Joannes-Boyau O, et al. Newly designed CRRT membranes for sepsis and SIRS--a pragmatic approach for bedside intensivists summarizing the more recent advances: a systematic structured review. ASAIO J 2013; 59:99. 

 2. Quintel M. CytoSorb™ whole blood cytokine adsorption–results of a controlled randomized trial. Presented at the 32nd International Symposium on Intensive Care and Emergency Medicine. March 20–23, 2012 

 3. Schadler, D., Brederlau J., Jorres, A., Marx, G., Meier-Hellmann, A., Putensen, C., Quintel, M., Spies, C., Porzelius, C., Engel, C., Weiler, N., Kuhlmann, M. Extracorporeal cytokine hemoadsorption in patients with severe sepsis and acute lung injury. Am J Respr Crit Care Med , 2013, pp.A5241

Sunday, June 14, 2020


Q: What is platelet contractile force (PCF)?


Platelet contractile force (PCF) is an interesting parameter to measure global platelet function. During platelet activation, contractile forces within the cytoskeleton of platelets mediate both changes of shape and pseudopod formation. PCF is a direct measurement of these forces. Despite normal platelet count, platelet function may be decreased in uremia, Glanzmann thrombasthenia, cardiopulmonary bypass, and GPIIb/IIIa inhibitors. 



1. Carr ME Jr, Zekert SL. Measurement of platelet-mediated force development during plasma clot formation. Am J Med Sci 1991; 302:13. 

2.  Carr ME Jr. Measurement of platelet force: the Hemodyne hemostasis analyzer. Clin Lab Manage Rev 1995; 9:312. 

3.  Greilich PE, Carr ME Jr, Carr SL, Chang AS. Reductions in platelet force development by cardiopulmonary bypass are associated with hemorrhage. Anesth Analg 1995; 80:459. 

4. Carr ME Jr, Carr SL, Hantgan RR, Braaten J. Glycoprotein IIb/IIIa blockade inhibits platelet-mediated force development and reduces gel elastic modulus. Thromb Haemost 1995; 73:499. 

5. Greilich PE, Carr ME, Zekert SL, Dent RM. Quantitative assessment of platelet function and clot structure in patients with severe coronary artery disease. Am J Med Sci 1994; 307:15.

Saturday, June 13, 2020

electrolyte abnormality after thyroidectomy

Q: Which electrolyte abnormality is common after thyroidectomy?

Answer: Calcium

Most of the patients develop hypocalcemia after thyroidectomy in the first 24 hours of surgery due to associated parathyroid gland manipulation. Every patient should be monitored for hypocalcemia immediately after surgery. This can be minimized or prevented with calcium replacements 2 weeks prior to surgery. Simultaneously keeping vitamin D levels above 20 ng/mL pre-surgery helps. Checking level of serum parathyroid hormone (PTH) immediately after surgery can predict the risk of hypocalcemia. The magnitude of the drop in serum PTH is a good predictor of the risk of postoperative hypocalcemia.




1. Hughes OR, Scott-Coombes DM. Hypocalcaemia following thyroidectomy for treatment of Graves' disease: implications for patient management and cost-effectiveness. J Laryngol Otol 2011; 125:849.

2. Landry CS, Grubbs EG, Hernandez M, et al. Predictable criteria for selective, rather than routine, calcium supplementation following thyroidectomy. Arch Surg 2012; 147:338. 

3. Noordzij JP, Lee SL, Bernet VJ, et al. Early prediction of hypocalcemia after thyroidectomy using parathyroid hormone: an analysis of pooled individual patient data from nine observational studies. J Am Coll Surg 2007; 205:748.

Friday, June 12, 2020

ASV mode

Q: Ventilator determines which of the following parameter to calculate the respiratory rate in Adaptive Support Ventilation (ASV) mode? (select one)

A) inspiratory time constant
B) expiratory time constant

Answer: B

ASV is a mode of ventilator in which respiratory mechanics of a patient dictate adjustments to the respiratory rate and inspiratory pressure to achieve the desired minute ventilation. Ventilator calculates these parameters depending on an expiratory time constant obtained from the expiratory limb of the flow volume loop on a breath by breath basis. So patients with a long expiratory time constant like in COPD receives a lower respiratory rate in comparison to patients with stiff lungs.

Although ASV  failed to show any benefit in mortality it may shorten the time to weaning initiation and weaning duration.



1. Arnal JM, Wysocki M, Nafati C, et al. Automatic selection of breathing pattern using adaptive support ventilation. Intensive Care Med 2008; 34:75. 

2. Kirakli C, Naz I, Ediboglu O, et al. A randomized controlled trial comparing the ventilation duration between adaptive support ventilation and pressure assist/control ventilation in medical patients in the ICU. Chest 2015; 147:1503.

Thursday, June 11, 2020

On Dig

Q: Can digoxin be called an inotrope by definition? (select one)

A) Yes
B) No

Answer: A

There are four classes of inotrope and digitalis in one of them. 

  •  Phosphodiesterase inhibitors - Milrinone & Enoximone 
  •  Beta-agonists - High-dose dopamine & Dobutamine 
  • Calcium-sensitizing agents - Levosimendan & oral Pimobendan 
  • Digitalis - Digoxin
All of these drugs have the property of direct inotropic effects and cause an increase in cardiac output.




1. Gheorghiade M, van Veldhuisen DJ, Colucci WS. Contemporary use of digoxin in the management of cardiovascular disorders. Circulation 2006; 113:2556.

2. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:1810.

3. Dec GW. Acute decompensated heart failure: the shrinking role of inotropic therapy. J Am Coll Cardiol 2005; 46:65.

Cough from ACE-I

Q: Although withdrawal of treatment is the choice of treatment for angiotensin converting enzyme inhibitors (ACE-Is) induced cough, which drugs may help to reduce the symptom?

Answer:  The treatment of choice in ACE-I induced cough is the withdrawal of the offending drug. But in case if cough lingers on despite the discontinuation of drug or in the situations where withdrawal is not feasible theophylline, inhaled sodium cromoglycate, picotamide(a thromboxane antagonist) may be helpful in alleviating the symptom. 

To note, in some cases cough may last up to three months after withdrawing the offending drug.



1. Cazzola M, Matera MG, Liccardi G, et al. Theophylline in the inhibition of angiotensin-converting enzyme inhibitor-induced cough. Respiration 1993; 60:212. 

2. Hargreaves MR, Benson MK. Inhaled sodium cromoglycate in angiotensin-converting enzyme inhibitor cough. Lancet 1995; 345:13. 

3. Malini PL, Strocchi E, Zanardi M, et al. Thromboxane antagonism and cough induced by angiotensin-converting-enzyme inhibitor. Lancet 1997; 350:15. 

4. Dicpinigaitis PV. Angiotensin-converting enzyme inhibitor-induced cough: ACCP evidence-based clinical practice guidelines. Chest 2006; 129:169S.

Wednesday, June 10, 2020

Burn and DVT

Q: In patients with severe burn DVT prophylaxis should be on hold for the first 72 hours of the management? 

 A) True 

B) False 

Answer: B

several physiologic changes occur in coagulation cascade of severely burned patients. These patients may be more prone to have DVT. Prophylaxis should be instituted early particularly in patients with burns >20 percent of total body surface area (TBSA) unless there is a risk of bleeding from associated trauma. For reasons not completely understood the risk of DVT is high in Afro-American patients. Other high-risk patients are those who require blood transfusions. Although fluid shifts during the resuscitation period of early burn may affect the efficacy of subcutaneous (SQ) administration of chemical prophylaxis it should not be stopped. Even the use of sequential compression devices is not contra-indicated.




Faucher LD, Conlon KM. Practice guidelines for deep venous thrombosis prophylaxis in burns. J Burn Care Res 2007; 28:661.

Tuesday, June 9, 2020

NGT placement

Q: While placing nasogastric tube (NGT) in a patient, it may help to tilt the head? (select one)

A) towards the chest
B) away from the chest

Answer: A

Studies have shown that the neck flexion results in a higher success rate of successful passage of NGT than with the neutral position. The most common sites for impaction/obstruction of the NGT are pyriform sinuses and the arytenoid cartilage. Flexion of the neck helps to keep the NGT in close proximity to the posterior pharyngeal wall and facilitates the smooth passage into the gastrointestinal (GI) tract.



1. Rajesh Mahajan, Rahul Gupta, Anju Sharma; Role of Neck Flexion in Facilitating Nasogastric Tube Insertion. Anesthesiology 2005;103(2):446-447. doi: https://doi.org/.

2. Ozer S, Benumof J: Oro and nasogastric tube passage in intubated patients: Fiber optic description of where they go at the laryngeal level and how to make them enter the esophagus. Anesthesiology 1999; 91:137–43

3. Ozer, S Benumof, J Bong LC, Macachar JD, Hwang NC: Insertion of the nasogastric tube made easy (letter). Anesthesiology 2004; 101:266

Monday, June 8, 2020

UGIB and history

Case: 52 year old male is admitted to ICU with an episode of upper gastrointestinal bleed (GIB). Patient mentioned having a similar episode 2 years ago and esophagogastroduodenoscopy (EGD) was performed. Why it would be important to look for the previous EGD report prior to a new EGD?

Answer: Although the data is old, it is still robust from a 23 years long study comprising of 14,000 patients. 60 percent of patients with a history of an upper GIB tend to bleed from the same lesion. As it may be easy to miss a small lesion in such situations, knowing the previous location not only shortens the procedure time but also helps to establish the progress, extension, and recurrence of the underlying disease which may have become life-threatening now. This includes varices or portal hypertensive gastropathy, angiodysplasia, peptic ulcer disease (PUD), and malignancy.



Palmer ED. The vigorous diagnostic approach to upper-gastrointestinal tract hemorrhage. A 23-year prospective study of 1,4000 patients. JAMA 1969; 207:1477.

Sunday, June 7, 2020


Q: Describe few conditions where Regional Citrate Anticoagulation (RCA) should be used with high caution during Continuous Renal Replacement Therapy (CRRT)?


RCA is commonly used with CRRT to avoid clotting of filters but there are few situations where RCA should be either on hold or use with caution.
  • Liver insufficiency particularly when transaminases  >1000 IU/L. Patients with such level of insufficiency can not metabolize citrate appropriately, causing severe acidosis.
  • Severe cardiogenic shock when blood lactate values >8 mmol/L. These patients also can not metabolize citrate adequately.
  • Any worsening metabolic acidosis with increasing anion gap 
  • Decreasing ionized calcium requiring escalating calcium infusion rates 
  • Increasing total calcium 
  • A ratio of total calcium to ionized calcium >2.5


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. 

3. 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. 

4. 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.

Saturday, June 6, 2020

transdermal patches and MRI

Q: Why transdermal patches should be removed prior to MRI?


Many transdermal patches contain aluminum or other metal in their nonadhesive backing and may cause skin burn. For safety reasons, these patches should be removed before MRI and reapplied afterwards. 

In case of nitroglycerin patch, medicine should be properly wiped off as it is combustible and carries extra hazard of fire in MRI suite.



Kuehn B. FDA warning: remove drug patches before MRI to prevent burns to skin. JAMA. 2009;301(13):1328

Friday, June 5, 2020

Diabetes and Plavix

Q: Diabetic patients may require? (select)

A) Higher dose of clopidogrel 
B) Lower dose of clopidogrel

Answer: A

Diabetic patients may require higher than standard dose of clopidogrel due to the reason that by default they have a higher percent of circulating immature platelets. This characteristics may counteract the inhibitory effect of clopidogrel on platelets. Although evidence in this regard is weak. Diabetic patients may respond better to other platelet inhibitor like prasugrel or ticagrelor.




1. Gurbel PA, Bliden KP, Hiatt BL, O'Connor CM. Clopidogrel for coronary stenting: response variability, drug resistance, and the effect of pretreatment platelet reactivity. Circulation 2003; 107:2908. 

2. Mangiacapra F, Patti G, Peace A, et al. Comparison of platelet reactivity and periprocedural outcomes in patients with versus without diabetes mellitus and treated with clopidogrel and percutaneous coronary intervention. Am J Cardiol 2010; 106:619. 

3. Gurbel PA, Bliden KP, Butler K, et al. Response to ticagrelor in clopidogrel nonresponders and responders and effect of switching therapies: the RESPOND study. Circulation 2010; 121:1188. 

Thursday, June 4, 2020

Lido with epi in SQ anesthesia

Q: What is the advantage of using epinephrine with lidocaine during subcutaneous (SQ) local anesthesia?


When epinephrine is added to lidocaine during SQ infiltration, it provides local vasoconstriction which prolongs the duration of action of local anesthesia. This action may last up to three hours. Also, it provides added advantage of decrease local bleeding, and reduce systemic lidocaine absorption. 

 Said that combination of lidocaine and epinephrine for local anesthesia should be avoided for digital anesthesia in patients with peripheral artery disease (PAD).




1. Stanton-Hicks, MD . Local anesthetics: Pharmacology and clinical applications. Hosp Formul 1987; 22:156. 

2. Kennedy RM, Luhmann JD. The "ouchless emergency department". Getting closer: advances in decreasing distress during painful procedures in the emergency department. Pediatr Clin North Am 1999; 46:1215. 

3.  Hruza, GJ. Anesthesia. In: Dermatology, 2nd, Bolognia, JL, Jorizzo, JL, Rapini, RP (Eds), Mosby Elsevier, Spain 2008. Vol 2, p.2173.

Wednesday, June 3, 2020

Exhaled nitric oxide analysis

Case:  23 year female with a long history of asthma is admitted to ICU with exacerbation of her symptoms. Despite standard therapies, she deteriorated and required intubation. Pulmonary service inquired about the availability of exhaled nitric oxide (eNO) analysis. What is the clinical application of exhaled nitric oxide (eNO) analysis?

Answer: It helps to suggest glucocorticoid responsiveness in Asthma

Nitric oxide (NO) has various functions in the bronchial tree. It regulates vascular and bronchial tone, facilitates the coordinated beating of ciliated epithelial cells, and acts as an important neurotransmitter for non-adrenergic, non-cholinergic neurons that run in the bronchial wall. NO can be measured in exhaled gas as the fraction of exhaled NO (FENO).

One of its major applications is found in asthmatic patients who usually have higher than normal levels of FENO.
  • FENO <25 ppb in asthmatics despite persistent symptoms suggests other etiologies for their symptoms, and suggests that inhaled glucocorticoid treatment may not be necessary
  • FENO >50 ppb even with atypical symptoms suggests glucocorticoid responsiveness



1. Blitzer ML, Loh E, Roddy MA, et al. Endothelium-derived nitric oxide regulates systemic and pulmonary vascular resistance during acute hypoxia in humans. J Am Coll Cardiol 1996; 28:591.

2. Dweik RA, Boggs PB, Erzurum SC, et al. An official ATS clinical practice guideline: interpretation of exhaled nitric oxide levels (FENO) for clinical applications. Am J Respir Crit Care Med 2011; 184:602.

Tuesday, June 2, 2020

Dig and Amyloidosis

Q: Why digoxin should be avoided in cardiac amyloidosis?

Answer:  Patients with cardiac amyloidosis are at a high risk of "dig toxicity" which usually outweighs any inotropic benefit. Digoxin binds avidly to amyloid fibrils. In these patients, cardiac digoxin concentration can't be accurately measured and serum digoxin level is extremely unreliable. If it is used in ICU for rate control in atrial fibrillation (chronotropic effect), a huge caution should be applied.




1. Rubinow A, Skinner M, Cohen AS. Digoxin sensitivity in amyloid cardiomyopathy. Circulation 1981; 63:1285. 

2. Falk RH. Diagnosis and management of the cardiac amyloidoses. Circulation 2005; 112:2047.

Monday, June 1, 2020

Electrical alternans

Q: Electrical alternans with sinus tachycardia has? (select one)

A) high specificity for pericardial effusion
B) high sensitivity for pericardial effusion

Answer: A

Electrical alternans is well known to be associated with pericardial effusion. It is defined as a cyclical beat-to-beat shift in the QRS axis in the limb and precordial leads due to mechanical swinging of the heart to-and-fro, in a large pericardial effusion. It is usually most apparent in one or more of the precordial leads. Also, it is usually accompanied by sinus tachycardia.

It has a high specificity when other clinical signs support cardiac tamponade. But it is not a sensitive sign. Its absence does not rule out cardiac tamponade.

Electrical alternans can also be observed in ventricular tachycardia, Wolff-Parkinson-White (WPW), accelerated idioventricular rhythm, and supraventricular tachycardia.



1. Goyal M, Woods KM, Atwood JE. Electrical alternans: a sign, not a diagnosis. South. Med. J. 2013 Aug;106(8):485-9. [PubMed]

2. Honasoge AP, Dubbs SB. Rapid Fire: Pericardial Effusion and Tamponade. Emerg. Med. Clin. North Am. 2018 Aug;36(3):557-565