Friday, July 31, 2020

Glucose in TH

Q: Hyperglycemia during Therapeutic Hypothermia (TH) is due to? (select one) 

A) insulin resistance 
B) increase body metabolism

Answer: A

Patients under therapeutic hypothermia are usually sedated with neuromuscular blockade on board in most of the standard protocols. Their body metabolism is actually low. Hyperglycemia during TH is due to insulin resistance. These patients require higher than normal doses of insulin. 
Said that close monitoring is required as many of these patients may have also encountered 'shock liver' and may have a caveat of hypoglycemia.



1. Cueni-Villoz N, Devigili A, Delodder F, et al. Increased blood glucose variability during therapeutic hypothermia and outcome after cardiac arrest. Crit Care Med 2011; 39:2225.

Thursday, July 30, 2020

Post C-section Anbx

Q: 32 year old patient is admitted to ICU with sepsis 48 hours after her cesarean section (C-section) surgery which was complicated by ruptured membranes. Reviewing the data you found that preoperative cefazolin was appropriately administrated 60 minutes prior to skin incision. Addition of which antibiotic may have prevented the sepsis?

Answer: Azithromycin 

In patients with high-risk C-section i.e., intrapartum cesareans and cesareans with ruptured membranes (at least 4 hours after), the addition of azithromycin is recommended. This is found to reduce the composite outcome of endometritis, wound infection, or any other infection without impacting the frequency of adverse neonatal outcomes by 50 percent.

Ideally, in such situations an infectious-Disease (ID) consult is warranted.




1. Tita AT, Szychowski JM, Boggess K, et al. Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. N Engl J Med 2016; 375:1231. 

2.  Tita ATN, Boggess K, Saade G. Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. N Engl J Med 2017; 376:182.

Wednesday, July 29, 2020

Octreotide in PUD

Q: What are the three beneficial effects of Octreotide in bleeding peptic ulcer?

Answer: Octreotide though commonly used in variceal bleeding is also found to be of benefit in bleeding peptic ulcers. It has three major effects

  •  reducing splanchnic blood flow 
  • inhibiting gastric acid secretion, and 
  • possible gastric cytoprotective effects 

It is usually used as a backup treatment where endoscopy is not feasible for the patient. It is also recommended as an adjunct treatment before endoscopy or failed endoscopy. 



1. Bloom SR, Mortimer CH, Thorner MO, et al. Inhibition of gastrin and gastric-acid secretion by growth-hormone release-inhibiting hormone. Lancet 1974; 2:1106. 

2. Johansson C, Aly A. Stimulation of gastric mucus output by somatostatin in man. Eur J Clin Invest 1982; 12:37. 

3. Imperiale TF, Birgisson S. Somatostatin or octreotide compared with H2 antagonists and placebo in the management of acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Ann Intern Med 1997; 127:1062.

Tuesday, July 28, 2020

CREST score

Q: How many features are there in CREST score?

 Answer: Five 

 There are two scores available to predict outcomes in out of hospital CPR. One is the NULL PLEASE score and the other is the CREST score. NULL PLEASE has 10 features in it which was presented yesterday at this site. To simplify it further CREST score has only five features. Moreover, CREST score is solely concentrated towards cardiac features. This is validated via a study from the registry of the International Cardiac Arrest Registry (INTCAR).
  •  Coronary artery disease history
  • Rhythm found to be unshockable
  • Ejection fraction less than 30%
  • Shock at presentation 
  • Time (prior to ROSC) >25 minutes 
 The risk of circulatory death increased with every additional point, from 10 percent mortality with CREST = 0 up to 50 percent mortality with CREST = 5.



Bascom KE, Dziodzio J, Vasaiwala S, et al. Derivation and Validation of the CREST Model for Very Early Prediction of Circulatory Etiology Death in Patients Without ST-Segment-Elevation Myocardial Infarction After Cardiac Arrest. Circulation 2018; 137:273.

Monday, July 27, 2020


Q: 48 year old male is admitted to ICU after out of hospital cardiac arrest. While giving hands-off, ED physician said his NULL Please score is high. What is NULL-PLEASE score?

 Answer: The NULL-PLEASE is a clinical risk score to predict survival after Sudden Cardiac Arrest in out of hospital settings. 

  • Nonshockable rhythm, 
  • Unwitnessed arrest, 
  • Long no-flow or Long low-flow period,  
  • PH less than 7 .2,
  • lactate more than 7.0 mmol/L, 
  • End-stage chronic kidney disease, 
  • Age ≥85 years, 
  • Still resuscitation, and 
  • Extracardiac cause



Potpara TS, Mihajlovic M, Stankovic S, et al. External Validation of the Simple NULL-PLEASE Clinical Score in Predicting Outcome of Out-of-Hospital Cardiac Arrest. Am J Med 2017; 130:1464.e13.

Sunday, July 26, 2020

PPE, COVID-19 and Healthcare workers

Q: Proper use of Personal Protective Equipment (PPE) while taking care of COVID-19 patients may provide? (select one)

A) partial protection
B) complete protection

Answer: B

It should be assuring to healthcare workers that multiple studies have now shown that proper use of PPE as well as donning and offing provides complete protection from the transmission while taking care of COVID-19 patients.  One large study of 420 providers from Wuhan China who performed at least one aerosol-generating procedure, none of them contracted the virus. Similarly, more or less compatible results were reported from New York and London, where the risk of transmission is not higher from the communities.




1. Liu M, Cheng SZ, Xu KW, et al. Use of personal protective equipment against coronavirus disease 2019 by healthcare professionals in Wuhan, China: cross sectional study. BMJ 2020; 369:m2195.

2. Hunter E, Price DA, Murphy E, et al. First experience of COVID-19 screening of health-care workers in England. Lancet 2020; 395:e77. 

3. Nagler AR, Goldberg ER, Aguero-Rosenfeld ME, et al. Early Results from SARS-CoV-2 PCR testing of Healthcare Workers at an Academic Medical Center in New York City. Clin Infect Dis 2020.

Saturday, July 25, 2020

dermatologic exam in acute stroke

Q: Why the dermatologic exam is vital in acute stroke?

Answer:   Often ignored are the few vital peripheral exams in acute stroke. It includes the dermatologic assessment. It is very much possible not to have immediate family members available to provide the relevant history. Skin exam may provide clues to the underlying disease if its a cause of stroke, like endocarditis, cholesterol emboli, purpura, ecchymoses (anticoagulation), recent surgery/procedure, trauma, seizure (tongue or lip laceration), distal ischemia, cellulitis (infection/inflammation/DIC), and deep vein thrombosis (DVT).


#physical exam


1. Arboix A, Obach V, Sánchez MJ, Massons J. Complementary examinations other than neuroimaging and neurosonology in acute stroke. World J Clin Cases. 2017;5(6):191-202. doi:10.12998/wjcc.v5.i6.191 

2. Yew KS, Cheng E. Acute stroke diagnosis. Am Fam Physician. 2009;80(1):33-40.

Friday, July 24, 2020

PSP and gender

Q: A primary spontaneous pneumothorax (PSP) is more common in?

A) male
B) female

Answer: A

The incidence of PSP is three to six times higher in males. This gets further compounded by geographic locations. The incidence of PSP is about five times higher in males and 15 times higher in females residing in the UK than in the USA. Although it is presumed that smoking or height may count for this discrepancy but the actual reason is unknown.




1. Light RW. Pleural Diseases, 6th ed, Lippincott, Williams and Wilkins, Philadelphia 2013.

Thursday, July 23, 2020


Q: What is Echophenomena?

Answer: Echophenomena is a neurological and psychiatric symptom and may present as
  •  Echolalia means senseless repetition of another person's words, or
  •  Echopraxia means senseless repetition of another person's movement
Echolalia is a common sign in patients with frontal lobe lesions, catatonia, dementia, and autism. Echopraxia though less common than echolalia can also be seen in frontal lobe disorders, catatonia, Tourette syndrome, and in schizophrenia.

Another related phenomenon is echolocation, but it is not a pathological sign. This is actually a virtue develop by many blind people. Alike bats and dolphins, blind people developed the ability to use self-generated sounds finger snaps to perceive the environment.



1. Ford RA. The psychopathology of echophenomena. Psychol Med. 1989;19(3):627-635. doi:10.1017/s0033291700024223

2. Schuler AL. Echolalia: issues and clinical applications. J Speech Hear Disord. 1979;44(4):411-434. doi:10.1044/jshd.4404.411

3. Hadano K, Nakamura H, Hamanaka T. Effortful echolalia. Cortex 1998;34:67-82. 

4. Pridmore S, Brune M, Ahmadi J, Dale J. Echopraxia in schizophrenia: possible mechanisms. Aust NZ J Psychiatry 2008;42:565-571.

Wednesday, July 22, 2020

Atropine in Dobutamine stress echo

Q: 64 year old female with past medical history (PMH) of hypertension (HTN) was admitted overnight to ICU with chest pain. This morning she underwent Dobutamine stress echocardiography. While writing her progress note you noted atropine was given while in the ECHO lab? (select one)

A) Patient 'coded' in the echo suite with bradycardia
B) Atropine is a regular part of Dobutamine stress echo

Answer: B

Atropine is frequently used in Dobutamine stress echocardiography to achieve target heart rate. Atropine is used in divided doses of 0.5 mg to a total of 2.0 mg. Atropine increases the sensitivity of dobutamine echocardiography in patients who are chronically on beta-blockers (BB). Another maneuver which can be applied to achieve target heart rate with or without atropine is to use a sustained isometric hand grip in the late stages of the dobutamine protocol as a supplement to achieve peak heart rate.



1. McNeill AJ, Fioretti PM, el-Said SM, et al. Enhanced sensitivity for detection of coronary artery disease by addition of atropine to dobutamine stress echocardiography. Am J Cardiol 1992; 70:41. 

2. Fioretti PM, Poldermans D, Salustri A, et al. Atropine increases the accuracy of dobutamine stress echocardiography in patients taking beta-blockers. Eur Heart J 1994; 15:355.

3. Ling LH, Pellikka PA, Mahoney DW, et al. Atropine augmentation in dobutamine stress echocardiography: role and incremental value in a clinical practice setting. J Am Coll Cardiol 1996; 28:551.

Tuesday, July 21, 2020

Normal water balance

Q: What are the components of water balance in a normal adult?

Answer: The basic understanding of hemodynamic cannot be understood without knowing the baseline normal components of water balance. A normal adult requires an obligatory minimum water balance of 1600 mL per day to keep his or her hemodynamic intact.


  • Ingested water = 500 mL 
  • Water in food = 800 mL 
  • Water from oxidation = 300 mL 

  • Urine = 500 mL 
  • Skin = 500 mL 
  • Respiratory tract  = 400 mL 
  • Stool = 200 mL



1. Roumelioti ME, Glew RH, Khitan ZJ, et al. Fluid balance concepts in medicine: Principles and practice. World J Nephrol. 2018;7(1):1-28. doi:10.5527/wjn.v7.i1.1

2. Rohrscheib M, Rondon-Berrios H, Argyropoulos C, Glew RH, Murata GH, Tzamaloukas AH. Indices of serum tonicity in clinical practice. Am J Med Sci. 2015;349:537–544.

Monday, July 20, 2020

non-cardiac signs and symptoms of atrial myxoma

Q: Describe a few non-cardiac signs and symptoms of atrial myxoma?

Answer: Atrial myxomas are interesting in the sense that they carry fascinating non-cardiac manifestations.
  • Fever of Unknown Origin (FUO) - up to one-third of cases 
  • Weight loss
  • Arthralgias
  • Emboli, and
  • hypergammaglobulinemia
  • anemia 
  • elevated erythrocyte sedimentation rate (ESR), 
  • Elevated C-reactive protein
Diagnosis is usually confirmed by echocardiography.    



1. Kuon E, Kreplin M, Weiss W, Dahm JB. The challenge presented by right atrial myxoma. Herz 2004; 29:702.

2. Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases. Medicine (Baltimore) 2001; 80:159. 

 3. Jelic J, Milicić D, Alfirević I, et al. Cardiac myxoma: diagnostic approach, surgical treatment and follow-up. A twenty years experience. J Cardiovasc Surg (Torino) 1996; 37:113. 

4. Maisch B. Immunology of cardiac tumors. Thorac Cardiovasc Surg 1990; 38 Suppl 2:157.

Sunday, July 19, 2020

Obesity and cancer

Q: Obese patients tend to have poor outcomes from chemotherapy?

A) True
B) False

Answer: A

The objective of the above question is to highlight one of the predictors which lead to poor outcomes in obese oncology patients. Most obese patients receive underdosing of anticancer agents. This is either due to the use of ideal or adjusted body weight or capping of the anti-cancer agent's dose. This issue has become more prevalent as the incidence of obesity has increased exponentially in society. With poor response more obese oncology patients tend to get admitted to ICU. 



1. Reeves GK, Pirie K, Beral V, et al. Cancer incidence and mortality in relation to body mass index in the Million Women Study: cohort study. BMJ 2007; 335:1134. 

2.  Field KM, Kosmider S, Jefford M, et al. Chemotherapy dosing strategies in the obese, elderly, and thin patient: results of a nationwide survey. J Oncol Pract 2008; 4:108. 

3.  Griggs JJ, Sorbero ME, Lyman GH. Undertreatment of obese women receiving breast cancer chemotherapy. Arch Intern Med 2005; 165:1267.

Saturday, July 18, 2020

Permissive hypotension in sepsis

Q: What was the target Mean Arterial Pressure (MAP) in the "permissive hypotension" group in the “65 trial” study?

A) 60-65 mm Hg
B) 65-70 mm Hg

Answer: A

A randomized controlled trial was published in 2020 to evaluate the effect of reduced exposure to vasopressors on 90-day mortality in older critically ill patients with vasodilatory hypotension. It was a multicenter trial conducted in UK's 65 ICUs and included 2600 randomized patients aged 65 years or older with vasodilatory hypotension. Patients were randomized 1:1 to vasopressors guided either by MAP target 60-65 mm Hg(permissive hypotension group) or according to usual care at the discretion of treating clinicians. Although the permissive hypotension group did not show a statistically significant reduction in mortality at 90 days, the data pointed towards benefit with the odds ratio for 90-day mortality of 0.82 (95% CI, 0.68 to 0.98). Moreover, there were no differences in the rates of cognitive dysfunction, arrhythmias, or acute kidney injury (AKI).



Lamontagne F, Richards-Belle A, Thomas K, et al. Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial. JAMA 2020.

Friday, July 17, 2020

Cryoprecipitate in uremic bleeding

Q: How cryoprecipitate helps in uremic bleeding?

Answer:  Cryoprecipitate shortens bleeding time in patients with uremia. Various factors present in Cryoprecipitate like factor VIII, von Willebrand factor multimers and fibrinogen enhances platelet aggregation. 10 units of cryoprecipitate may become effective within one hour of infusion. Cryoprecipitate can be used if standard treatments like platelet transfusion or desmopressin (DDAVP) fails to do the task.



Janson PA, Jubelirer SJ, Weinstein MJ, Deykin D. Treatment of the bleeding tendency in uremia with cryoprecipitate. N Engl J Med 1980; 303:1318.

Thursday, July 16, 2020

CPR in venous air embolism

Q: How chest compressions may help in venous air embolism even if patient has not lost a pulse?

Answer: The objective of the above question is to bring to light a less known intervention during venous air embolism where a patient may not lose pulse but become hemodynamically unstable. Technically called "closed chest cardiac massage" may help to force air out of the pulmonary outflow tract and into smaller pulmonary vessels, improving forward blood flow. 

In vitro studies suggest that closed-chest cardiac massage is as effective as left lateral decubitus position and intra-cardiac aspiration of air.



1. Alvaran SB, Toung JK, Graff TE, Benson DW. Venous air embolism: comparative merits of external cardiac massage, intracardiac aspiration, and left lateral decubitus position. Anesth Analg 1978; 57:166. 


Wednesday, July 15, 2020

Transmission of VZV

Q: Varicella-zoster virus (VZV) in hospitals can be transmitted via inanimate objects? (select one)

A) True
B) False

Answer: B

Few things are relatively less know about VZV infection. 

  •  Humans are the only known hosts of VZV infection
  • VZV is transmitted in humans by droplet and airborne routes
  • VZV is very labile and unlikely to be transmitted by inanimate objects
Exposure to airflow from rooms occupied by patients with VZV is one of the major risk factors transmission.



1. Weber DJ, Rutala WA, Hamilton H. Prevention and control of varicella-zoster infections in healthcare facilities. Infect Control Hosp Epidemiol 1996; 17:694

2. Bloch KC, Johnson JG. Varicella zoster virus transmission in the vaccine era: unmasking the role of herpes zoster. J Infect Dis. 2012;205(9):1331-1333. doi:10.1093/infdis/jis214

Tuesday, July 14, 2020


Q: The definition of acute exacerbation(AE) of Idiopathic Pulmonary Fibrosis (IPF) requires a 30 day limit for symptom onset and exclusion of infection?

A) True
B) False

Answer: B

In 2016, the revised definition of AE in IPF by the Idiopathic Pulmonary Fibrosis Network (IPFnet) excluded the previous two requirements from the 2007 definition i.e., an exact 30 day limit for symptom onset and exclusion of infection. In 2016, the proposed definition is"an acute, clinically significant respiratory deterioration characterized by evidence of new widespread alveolar abnormality." The proposed diagnostic criteria are: 

  • A known diagnosis of IPF (the diagnosis may be made at the time of acute respiratory deterioration).
  • Acute worsening, "typically less than one month's duration" 
  •  CT of the chest with new bilateral ground-glass opacification and/or consolidation superimposed on a background of findings consistent with usual interstitial pneumonia (bibasilar reticular opacities associated with honeycomb changes and traction bronchiectasis)  
  • Heart failure or fluid overload does not fully explain the worsening.


Collard HR, Ryerson CJ, Corte TJ, et al. Acute Exacerbation of Idiopathic Pulmonary Fibrosis. An International Working Group Report. Am J Respir Crit Care Med 2016; 194:265.

Monday, July 13, 2020

Serum lactate in abdominal ischemia

Q: Serum lactate in abdominal ischemia has? (select one)

A) high sensitivity
B) high specificity
C) both

Answer: A

Unfortunately, despite being a known and widespread clinical entity, abdominal ischemia has no specific clinical or laboratory marker. Serum lactate continues to be the most widely used laboratory marker. It is very sensitive for abdominal ischemia (90 to 100 percent) but has low specificity (42 to 87 percent).



1. Murray MJ, Gonze MD, Nowak LR, Cobb CF. Serum D(-)-lactate levels as an aid to diagnosing acute intestinal ischemia. Am J Surg 1994; 167:575. 

2. Lange H, Jäckel R. Usefulness of plasma lactate concentration in the diagnosis of acute abdominal disease. Eur J Surg 1994; 160:381.

Sunday, July 12, 2020

Recurrence of life-threatening hemoptysis and arteriographic embolization

Q: Recurrence of life-threatening hemoptysis is higher in patients who undergo arteriographic embolization?

A) True
B) False

Answer: A

Arterial embolization has its unique advantage in extremely acute cases where it can successfully stop the bleeding in the majority of the cases. But, there is always a higher chance of recurrence of bleed in 6 to 12 months. The causes include incomplete embolization, revascularization, or recanalization. Some diseases tend to give recurrence of bleeding more like bleeding from aspergillomas, tuberculosis, bronchiectasis, non-bronchial systemic collateral vessels, and bronchopulmonary shunting.




1. Mal H, Rullon I, Mellot F, et al. Immediate and long-term results of bronchial artery embolization for life-threatening hemoptysis. Chest 1999; 115:996. 

2. White RI Jr. Bronchial artery embolotherapy for control of acute hemoptysis: analysis of outcome. Chest 1999; 115:912. 

3. Osaki S, Nakanishi Y, Wataya H, et al. Prognosis of bronchial artery embolization in the management of hemoptysis. Respiration 2000; 67:412. 

4.  Panda A, Bhalla AS, Goyal A. Bronchial artery embolization in hemoptysis: a systematic review. Diagn Interv Radiol 2017; 23:307. 

5. Tom LM, Palevsky HI, Holsclaw DS, et al. Recurrent Bleeding, Survival, and Longitudinal Pulmonary Function following Bronchial Artery Embolization for Hemoptysis in a U.S. Adult Population. J Vasc Interv Radiol 2015; 26:1806.

Saturday, July 11, 2020

Cough from ACE inhibitors

Q: Cough from ACE inhibitors is more common in?

A) Men
B) Women

Answer: B

ACE inhibitors degrade bradykinin and its accumulation leads to stimulation of afferent C-fibers in the airway causing cough. It usually starts within a week of instituting therapy though there are reports of delayed onset up to six months. The classic description is like a tickling, scratchy, or itchy sensation in the throat. It is more common in women and in patients of Chinese origin. Fortunately, it is not known to cause any airflow obstruction. Treatment is discontinuing of ACE inhibitor. It is said that losartan or another angiotensin II receptor antagonist can be tried as a substitute.  




1. Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest 2006; 129:1S.

2.  Dykewicz MS. Cough and angioedema from angiotensin-converting enzyme inhibitors: new insights into mechanisms and management. Curr Opin Allergy Clin Immunol 2004; 4:267.

3. Tseng DS, Kwong J, Rezvani F, Coates AO. Angiotensin-converting enzyme-related cough among Chinese-Americans. Am J Med 2010; 123:183.e11.

Friday, July 10, 2020

sarcoidosis and fatigue

Q:  History of high fatigue in a patient with sarcoidosis points towards? (select one)

A) Pulmonary Sarcoidosis
B) Extra-pulmonary Sarcoidosis

Answer: B

Fatigue is a common complaint in patients with most of the sarcoidosis patients. It is very interesting that higher level of fatigue in sarcoid patient is found to be associated with presence of extrapulmonary sarcoidosis. In other words, though sounds paradox but fatigue is less pronounced in patients with only pulmonary sarcoid. Further investigation also showed that patients with extra-pulmonary sarcoidosis have higher resting energy expenditure and increased C-reactive protein (CRP).




1. de Kleijn WP, De Vries J, Lower EE, et al. Fatigue in sarcoidosis: a systematic review. Curr Opin Pulm Med 2009; 15:499. 

2. Fleischer M, Hinz A, Brähler E, et al. Factors associated with fatigue in sarcoidosis. Respir Care 2014; 59:1086. 

3. Drent M, Wirnsberger RM, de Vries J, et al. Association of fatigue with an acute phase response in sarcoidosis. Eur Respir J 1999; 13:718.

Thursday, July 9, 2020


Q: What is the utility of Plasmodium lactate dehydrogenase (pLDH) in the treatment of Malaria?

Answer:  pLDH is different in structure from human LDH and is produced by asexual and sexual forms of all Plasmodium species. pLDH-based assays can be used to predict success or failure of malaria treatment as serum pLDH levels correlate with parasite density and usually become undetectable from blood following antimalarial therapy. It may also identify asymptomatic patients with relatively low parasite densities.


1. Makler MT, Piper RC, Milhous WK. Lactate dehydrogenase and the diagnosis of malaria. Parasitol Today 1998; 14:376. 

2. Makler MT, Hinrichs DJ. Measurement of the lactate dehydrogenase activity of Plasmodium falciparum as an assessment of parasitemia. Am J Trop Med Hyg 1993; 48:205. 

3. Oduola AM, Omitowoju GO, Sowunmi A, et al. Plasmodium falciparum: evaluation of lactate dehydrogenase in monitoring therapeutic responses to standard antimalarial drugs in Nigeria. Exp Parasitol 1997; 87:283.

Wednesday, July 8, 2020

mannitol induced "rebound" increase in ICP

Q: How mannitol can induce a "rebound" increase in Intra Cranial Pressure (ICP)?

Answer:  Mannitol is the most commonly used osmotic diuretic in neurosurgical ICUs to reduce ICP. It is frequently given every six to eight hours. When given in repeated doses, mannitol may enter the brain through a damaged blood-brain barrier and reverses the osmotic gradient resulting in a "rebound" increase in ICP. Mannitol therapy can be monitored or curtailed when serum sodium goes >150 mEq, serum osmolality rises >320 mOsm, or there is any evidence of evolving acute tubular necrosis (ATN). Also, mannitol can acutely drop systemic blood pressure resulting in decreased cerebral perfusion pressure (CPP).




1. Jafar JJ, Johns LM, Mullan SF. The effect of mannitol on cerebral blood flow. J Neurosurg 1986; 64:754. 

2. Kaufmann AM, Cardoso ER. Aggravation of vasogenic cerebral edema by multiple-dose mannitol. J Neurosurg 1992; 77:584. 

Tuesday, July 7, 2020

FOUR score

Q: What are the four components of the Full Outline of UnResponsiveness (FOUR) score of neurological exam? 

 Answer: The Full Outline of UnResponsiveness (FOUR) score is an alternative scale assessment scale of neurological exam besides Glasgow coma scale (GCS) particularly in patients with Traumatic Brain Injury (TBI). It has the advantage of being useful even in intubated patients. It has four components

  • Eyelids response 
  • Motor response
  • Brainstem reflexes (pupil, cornea and cough reflexes)
  • Respiration 
The online score calculator can be found at



Wijdicks EF, Bamlet WR, Maramattom BV, et al. Validation of a new coma scale: The FOUR score. Ann Neurol 2005; 58:585. 

McNett MM, Amato S, Philippbar SA. A Comparative Study of Glasgow Coma Scale and Full Outline of Unresponsiveness Scores for Predicting Long-Term Outcome After Brain Injury. J Neurosci Nurs 2016; 48:207. 

Kasprowicz M, Burzynska M, Melcer T, Kübler A. A comparison of the Full Outline of UnResponsiveness (FOUR) score and Glasgow Coma Score (GCS) in predictive modelling in traumatic brain injury. Br J Neurosurg 2016; 30:211.

Monday, July 6, 2020

Peroneal motor amplitude

Q: What is the best test to predict Critical Illness Myopathy (CIM) or Critical Illness Polyneuropathy (CIP) in ICU patients? 

Answer:  Peroneal motor amplitude

The CRIMYNE study was published in 2007 with a sample size of 92 patients. It has shown that a reduction of >25 percent in the peroneal motor amplitude (compound muscle action potential) on two consecutive days can predict CIM and/or CIP with 100 percent sensitivity and 67 percent specificity. Followup validity studies including CRIMYNE-2 study confirmed 94-100 sensitivity and 85-91 percent specificity. In these studies, all of the patients had normal nerve conduction 24 hours after ICU admission. Serial electrodiagnostic studies were performed. CRIMYNE study also showed that the timing of development to CIM and/or CIP cannot be predicted. It may occur abruptly within a day or over many days. Interestingly, though an association was found with multiorgan failure, there was no association found with SIRS, sepsis, drugs, or nutrition which have been conventionally believed to be factors.



Latronico N, Bertolini G, Guarneri B, et al. Simplified electrophysiological evaluation of peripheral nerves in critically ill patients: the Italian multi-centre CRIMYNE study. Crit Care 2007; 11:R11.

Latronico N, Nattino G, Guarneri B, et al. Validation of the peroneal nerve test to diagnose critical illness polyneuropathy and myopathy in the intensive care unit: the multicentre Italian CRIMYNE-2 diagnostic accuracy study. F1000Res 2014; 3:127.

Kelmenson DA, Quan D, Moss M. What is the diagnostic accuracy of single nerve conduction studies and muscle ultrasound to identify critical illness polyneuromyopathy: a prospective cohort study. Crit Care 2018; 22:342.

Sunday, July 5, 2020


Q: Unfractionated Heparin has more risk of bleeding than Low Molecular Weight Heparin (LMWH? (select one)

A) True
B) False

Answer: A

Data from the 2017 Cochrane review showed that unfractionated heparin potentially carries an increased risk of hemorrhagic complications compared with LMWH. This effect is particularly pronounced in patients with cirrhosis due to their inherent risk of bleeding due to coagulopathy. 

Surprisingly, there is also weak evidence that the incidence of bleeding complications found to be lower with a once-daily dose, compared to commonly prescribed twice-daily dosing of LMWH. This may be due to the fact that the risk of bleeding correlates better with the trough of the drug concentrations.



1. Robertson L, Jones LE. Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for the initial treatment of venous thromboembolism. Cochrane Database Syst Rev 2017; 2:CD001100. 

2. Summers, K.L., Davis, K.A. & Nisly, S.A. Bleeding Risk of Therapeutic Unfractionated Heparin and Low Molecular Weight Heparin in Patients with Cirrhosis. Clin Drug Investig 40, 191–196 (2020). 

3. Costantino G, Ceriani E, Rusconi AM, et al. Bleeding risk during treatment of acute thrombotic events with subcutaneous LMWH compared to intravenous unfractionated heparin; a systematic review. PLoS One. 2012;7(9):e44553. doi:10.1371/journal.pone.0044553

Friday, July 3, 2020


Q: What are the acceptable QT intervals in the hospital settings?

Answer: Relatively longer QT intervals are acceptable in hospital settings. Although calculated QT interval from EKG machine has become a norm, ideally all patients with suspected acquired Long QT syndrome (LQTS) should have a QT interval measured manually on all available EKGs including the old ones. Leads II and V5 are preferred. This measurement should be corrected for the heart rate (QTc). 

 The American Heart Association/American College of Cardiology (AHA/ACC) scientific statement on prevention of Torsades de Pointes (TdP) recommended the following limits for QTc 
 in hospital settings

  •  >470 milliseconds for men, and
  •  >480 milliseconds for women



Drew BJ, Ackerman MJ, Funk M, et al. Prevention of torsade de pointes in hospital settings: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. Circulation 2010; 121:1047.

Thursday, July 2, 2020

medication-induced anaphylaxis

Q: Which patients' population is more prone to have medication-induced anaphylaxis? (select one) 

A) Adult
B) Children

Answer: A

Contrary to popular belief, medication-induced anaphylaxis is more common in adults than children or adolescents. The most common categories implicated in this side-effect are 

  • Beta-lactam antibiotics (penicillins and cephalosporins) 
  • Radiocontrast agents 
  • Neuromuscular blockers
  • anesthetics
  • Allergen immunotherapy
  • Other antibiotics



1. Mullins RJ, Wainstein BK, Barnes EH, et al. Increases in anaphylaxis fatalities in Australia from 1997 to 2013. Clin Exp Allergy 2016; 46:1099.

2. Turner PJ, Jerschow E, Umasunthar T, et al. Fatal Anaphylaxis: Mortality Rate and Risk Factors. J Allergy Clin Immunol Pract 2017; 5:1169.

3. Turner PJ, Gowland MH, Sharma V, et al. Increase in anaphylaxis-related hospitalizations but no increase in fatalities: an analysis of United Kingdom national anaphylaxis data, 1992-2012. J Allergy Clin Immunol 2015; 135:956.

4. Pumphrey R. Anaphylaxis: can we tell who is at risk of a fatal reaction? Curr Opin Allergy Clin Immunol 2004; 4:285.

Wednesday, July 1, 2020

Bladder scan

Q: Bedside portable ultrasound units for urinary bladder (BladderScan®️) are very sensitive to estimate residual urinary volume?

A) True
B) False

Answer: A

Unfortunately, many ICU patients continue to have urinary catheters despite no actual indication leading to high Catheter-Associated Urinary Tract Infections (CAUTIs). Ideally, a patient should be allowed to void. If there is a suspicion of retained urine in the bladder, portable ultrasound units can be very sensitive to estimate residual volume greater than 50 mL in most of the patients. This may help in deciding the volume status of patients and can help in avoiding improper insertions of urinary catheters.




1. Holroyd-Leduc JM, Sands LP, Counsell SR, et al. Risk factors for indwelling urinary catheterization among older hospitalized patients without a specific medical indication for catheterization. J Patient Saf 2005; 1:201. 

2. Fuse H, Yokoyama T, Muraishi Y, Katayama T. Measurement of residual urine volume using a portable ultrasound instrument. Int Urol Nephrol 1996; 28:633.