Monday, May 31, 2021

Calcium in tyhroid storm

 Q: Which is more common in thyroid storm?

A) Hypercalcemia 

B) Hypocalcemia

Answer: A

There is only one specific laboratory marker in thyroid storm i.e., low TSH and high free T4 and/or T3. All other laboratory findings are non-specific but help in making the diagnosis. One of such non-specific but important laboratory findings is hypercalcemia though mostly at a milder level. This is due to increased bone resorption and hemoconcentration. 

Other associated findings can be hyperglycemia and abnormal LFT. Interestingly, CBC can have either leukocytosis or leukopenia.



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

Sunday, May 30, 2021

simethicone add in the bowel preparation

 Q: 58 years old male is admitted to ICU with lower gastrointestinal bleed (LGIB). Consulting service requests to add simethicone to the bowel preparation. What is the advantage of adding simethicone to bowel preparation? 

Answer: Visualization during colonoscopy can be restricted due to the high gas bubbles burden. Simethicone is used during the procedure to reduce gas bubbles. Simethicone use in the midst of the procedure carries an inherent risk of contamination. This persists despite proper procedures followed for disinfection and reprocessing methods. This objective can be achieved by adding simethicone to the bowel preparation before the procedure./span>



1. Barakat MT, Huang RJ, Banerjee S. Simethicone is retained in endoscopes despite reprocessing: impact of its use on working channel fluid retention and adenosine triphosphate bioluminescence values (with video). Gastrointest Endosc 2019; 89:115. 

2. Moraveji S, Casner N, Bashashati M, et al. The role of oral simethicone on the adenoma detection rate and other quality indicators of screening colonoscopy: a randomized, controlled, observer-blinded clinical trial. Gastrointest Endosc 2019; 90:141.

Saturday, May 29, 2021

Griffiths' point

 Q: What is Griffiths' point? 

Answer: The two most high-risk areas in intestinal ischemia are splenic flexure and rectosigmoid junction. 

Griffiths' point is the area for splenic flexure which is the cause of concern. It is defined as the site of communication of the ascending left colic artery (LCA) with the marginal artery (MA) of Drummond, and anastomotic bridging between the right and left terminal branches of the ascending LCA at the splenic flexure of the colon. 

Similarly, the area for concern for rectosigmoid junction is called Sudeck's point, where the descending branch of the LCA makes an anastomosis with the superior branches of the rectal artery, also known as hemorrhoidal artery.  



1. Meyers MA. Griffiths' point: critical anastomosis at the splenic flexure. Significance in ischemia of the colon. AJR Am J Roentgenol 1976; 126:77.

2. van Tonder JJ, Boon JM, Becker JH, van Schoor AN. Anatomical considerations on Sudeck's critical point and its relevance to colorectal surgery. Clin Anat 2007; 20:424.

Friday, May 28, 2021

ETOH and acetaminophen toxicity

Q: Ingestion of alcohol and acetaminophen together increases the risk of acute acetaminophen toxicity by many folds?

A) True

B) False

Answer: B

It may be of surprise but acute alcohol ingestion may be protective against acute acetaminophen toxicity. This is due to the fact that alcohol is a substrate of the CYP2E1 enzyme. It may lower the risk by almost two-third. Alcohol competes with acetaminophen for CYP2E1 and decreases the amount of NAPQI produced. 

CYP2E1 is a member of the cytochrome P450 mixed-function oxidase system, and NAPQI is N-acetyl-p-benzoquinone imine, a toxic byproduct produced during acetaminophen metabolism.



1. Thummel KE, Slattery JT, Nelson SD. Mechanism by which ethanol diminishes the hepatotoxicity of acetaminophen. J Pharmacol Exp Ther 1988; 245:129. 

2. Slattery JT, Nelson SD, Thummel KE. The complex interaction between ethanol and acetaminophen. Clin Pharmacol Ther 1996; 60:241. 

3. Waring WS, Stephen AF, Malkowska AM, Robinson OD. Acute ethanol coingestion confers a lower risk of hepatotoxicity after deliberate acetaminophen overdose. Acad Emerg Med 2008; 15:54.

Thursday, May 27, 2021

components of delirium

 Q: What are the five components to define delirium?

Answer: Over the last two decades delirium has been identified as one of the most influential factors in short and long-term outcomes of hospitalized patients. By definition it should have five components:

  • acute
  • potentially reversible 
  • impairment of consciousness 
  • impairment of cognitive function 
  • fluctuates in severity

It is of vital importance to understand the statement that "Delirium is an organic mental syndrome." It is defined as: "an acute and potentially reversible impairment of consciousness and cognitive function that fluctuates in severity."



Hansen-Flaschen J. Improving patient tolerance of mechanical ventilation. Challenges ahead. Crit Care Clin 1994; 10:659.

Wednesday, May 26, 2021

ESR for age

 Q: What's the formula to correct Erythrocyte Sedimentation Rate (ESR) for age?

Answer: Non-specific or benign elevation in ESR can occur in the following situations: 

  • age 
  • female gender 
  • anemia 
  • kidney disease 
  • obesity 
  •  Labs high temperature (common in hot climate) 

Age and female sex are the most common causes in the population for an isolated non-specific elevated ESR. The ballpark (not very specific) formulae to correct the upper limit of the reference range of ESR are 

Men = (age in years)/2 

Female = (age in years + 10)/2



1. Miller A, Green M, Robinson D. Simple rule for calculating normal erythrocyte sedimentation rate. Br Med J (Clin Res Ed) 1983; 286:266. 

2. Arik N, Bedir A, Günaydin M, et al. Do erythrocyte sedimentation rate and C-reactive protein levels have diagnostic usefulness in patients with renal failure? Nephron 2000; 86:224. 

3. Leff RD, Akre SP. Obesity and the erythrocyte sedimentation rate. Ann Intern Med 1986; 105:143.

Tuesday, May 25, 2021

Treatment in serotonin Syndrome

 Q: All of the following should be avoided as a treatment in serotonin syndrome EXCEPT? (select one) 

A) Chlorpromazine 

B) Benzodiazepine 

C) Propranolol 

D) Bromocriptine 

E) Dantrolene

Answer: B

Except for sedation (benzodiazepine), discontinuation of an offending drug, and supportive treatment, none of the treatments has shown any benefit in serotonin syndrome. Although cyproheptadine is widely used, it has a very weak evidence of direct benefit. Due to its low-risk, it is ok to use as benefit outweighs the risk.

Chlorpromazine can worsen hyperthermia of serotonin syndrome (choice A).

Propranolol with its long duration of action may mask tachycardia and misguide clinicians (choice C). 

Bromocriptine is also found to make serotonin syndrome worse (choice D). 

Dantrolene is the treatment for malignant hyperthermia and has no role in serotonin syndrome (choice E).



1. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005; 352:1112. 

2. Nisijima K, Shioda K, Yoshino T, et al. Diazepam and chlormethiazole attenuate the development of hyperthermia in an animal model of the serotonin syndrome. Neurochem Int 2003; 43:155. 

3. Graudins A, Stearman A, Chan B. Treatment of the serotonin syndrome with cyproheptadine. J Emerg Med 1998; 16:615.

Monday, May 24, 2021

Remdesivir in organ failures

 Q: Remdesivir should be given to patients with caution in? (select one)

A) Liver insufficiency

B) Kidney insufficiency

C) Both liver and kidney insufficiencies

D) Irrespectively all COVID 19 patients should get it

Answer: C

Remdesivir has become one of the mainstays of the treatment in COVID-19. Remdesivir's contraindication in liver insufficiency is well-known. The objective of this question is to highlight its effect with renal insufficiency. Remdesivir itself is not harmful to the kidney. Actually, the vehicle in which it is prepared i.e., cyclodextrin can accumulate in renal insufficiency and may become toxic for the body. So far there is no established quantification. At this point, it is recommended to be avoided in patients with an estimated glomerular filtration rate (eGFR) of less than 30 mL/min per 1.73 m2. Said that a decision should be made clinically per individual patient. 

If a clinician decides to use Remdesivir in a patient on continuous renal replacement therapy (CRRT), hemodialysis (HD), or extracorporeal membrane oxygenation (ECMO), no dose adjustment is required. In fact, it may require a higher dose due to its potential of removal or sequestration. A pharmacist should be consulted. Moreover, Remdesivir should not be prescribed with hydroxychloroquine or chloroquine. It may cause a fatal drug interaction.





1. (Accessed on May 23, 2021). 

2. Chaijamorn W, Rungkitwattanakul D, Nuchtavorn N, et al. Antiviral Dosing Modification for Coronavirus Disease 2019-Infected Patients Receiving Extracorporeal Therapy. Crit Care Explor. 2020;2(10):e0242. Published 2020 Oct 1. doi:10.1097/CCE.0000000000000242

3. Adamsick ML, Gandhi RG, Bidell MR, et al. Remdesivir in Patients with Acute or Chronic Kidney Disease and COVID-19. J Am Soc Nephrol 2020; 31:1384. 

4. Thakare S, Gandhi C, Modi T, et al. Safety of Remdesivir in Patients With Acute Kidney Injury or CKD. Kidney Int Rep 2021; 6:206.

Sunday, May 23, 2021

culture-negative endocarditis and Bartonella

 Q: Describe a few associated risk factors in culture-negative endocarditis where Bartonella should be covered with antibiotics?

Answer:  Bartonella is considered a significant cause of culture-negative endocarditis. Interestingly more than two-third of cases involved are in men. Other risk factors are

  • homelessness
  • alcoholism
  • infestation with body lice 
  • contact with cats
  • valvular heart disease 
  • history of HIV
Clinical significance: Clinical suspicion to cover Bartonella is important in culture-negative endocarditis. It takes time for the blood culture for Bartonella to turn positive. Also, it requires a special stain and PCR to establish the diagnosis. Antibiotic coverage requires doxycycline, aminoglycoside, and +/- ceftriaxone. 



1. Spach DH, Callis KP, Paauw DS, et al. Endocarditis caused by Rochalimaea quintana in a patient infected with human immunodeficiency virus. J Clin Microbiol 1993; 31:692.

2. Raoult D, Fournier PE, Vandenesch F, et al. Outcome and treatment of Bartonella endocarditis. Arch Intern Med 2003; 163:226.

3. Ghidey FY, Igbinosa O, Mills K, et al. Case series of Bartonella quintana blood culture-negative endocarditis in Washington, DC. JMM Case Rep 2016; 3:e005049. 

4. Fournier PE, Lelievre H, Eykyn SJ, et al. Epidemiologic and clinical characteristics of Bartonella quintana and Bartonella henselae endocarditis: a study of 48 patients. Medicine (Baltimore) 2001; 80:245.

Saturday, May 22, 2021

Fondaparinux and HIT

Q: Fondaparinux like other low molecular weight heparins (LMWH) may cause heparin-induced thrombocytopenia (HIT)? 

A) True 
B) False

Answer: B

Fondaparinux is one of the unique low molecular weight heparins which does not cause HIT. It is an indirect inhibitor of factor Xa, but does not inhibit thrombin and does not interact with platelets or platelet factor 4 (PF-4). Also, Fondaparinux is 100 percent bioavailable after SQ administration. 

Despite these advantages, Fondaparinux never gets much popular in US hospitals due to various reasons. It has a very pretty long half-life of 15-17 hours, and in case of bleeding, there is no specific antidote. It takes three to five half-lives which translates to two to four days till all bleeding risks subside. Also, it gets eliminated via kidney, and renal insufficiency is widely common in ICU patients.



1. Linkins LA, Hu G, Warkentin TE. Systematic review of fondaparinux for heparin-induced thrombocytopenia: When there are no randomized controlled trials. Res Pract Thromb Haemost. 2018 Aug 9;2(4):678-683. doi: 10.1002/rth2.12145. PMID: 30349886; PMCID: PMC6178656. 

2. Warkentin TE, Cook RJ, Marder VJ, et al. Anti-platelet factor 4/heparin antibodies in orthopedic surgery patients receiving antithrombotic prophylaxis with fondaparinux or enoxaparin. Blood 2005; 106:3791. 

3. Warkentin TE. Fondaparinux: does it cause HIT? Can it treat HIT? Expert Rev Hematol. 2010 Oct;3(5):567-81. doi: 10.1586/ehm.10.54. PMID: 21083474.

Friday, May 21, 2021

corticosteroids in CNS toxoplasmosis

 Q: What is the caveat of using corticosteroids during the management of CNS toxoplasmosis?

Answer: It is not absolutely necessary to add corticosteroids in the management of toxoplasmosis. It should be used judiciously if there is a mass effect in the brain, edema or midline shift. 

Corticosteroids can deceive the actual underlying progress of the patients' response by rapidly improving only the symptoms. It reduces the ring enhancement and surrounding edema, but may also lead to secondary opportunistic infections, which can be detrimental in these immunocompromised patients.



1. Sonneville R, Schmidt M, Messika J, Ait Hssain A, da Silva D, Klein IF, Bouadma L, Wolff M, Mourvillier B. Neurologic outcomes and adjunctive steroids in HIV patients with severe cerebral toxoplasmosis. Neurology. 2012 Oct 23;79(17):1762-6. doi: 10.1212/WNL.0b013e3182704040. Epub 2012 Oct 10. PMID: 23054235. 

2. Vidal JE. HIV-Related Cerebral Toxoplasmosis Revisited: Current Concepts and Controversies of an Old Disease. J Int Assoc Provid AIDS Care. 2019;18:2325958219867315. doi:10.1177/2325958219867315

Thursday, May 20, 2021

lithium toxicity

 Q: EKG changes in lithium toxicity can be fatal? 

A) True

B) False

Answer: B

Despite EKG changes, cardiac events are rare in acute or chronic lithium toxicity. It is actually neurological symptoms that are more worrisome. Common EKG findings are bradycardia with flattened T waves and prolonged QTc intervals. 

Acute lithium toxicity causes nausea, vomiting, and diarrhea. Hydration in this phase is of clinical importance as dehydration can exacerbate lithium toxicity and lead to acute kidney failure. 

Neurologic findings imply a late phase of toxicity. It may cause confusion, agitation, tremors, fasciculations, myoclonic jerks, and seizures. Hemodialysis is indicated.



1. Demers RG, Heninger GR. Electrocardiographic T-wave changes during lithium carbonate treatment. JAMA 1971; 218:381. 

2. Offerman SR, Alsop JA, Lee J, Holmes JF. Hospitalized lithium overdose cases reported to the California Poison Control System. Clin Toxicol (Phila) 2010; 48:443. 

3. Adityanjee, Munshi KR, Thampy A. The syndrome of irreversible lithium-effectuated neurotoxicity. Clin Neuropharmacol 2005; 28:38. 

4. Rose SR, Klein-Schwartz W, Oderda GM, et al. Lithium intoxication with acute renal failure and death. Drug Intell Clin Pharm 1988; 22:691.

Wednesday, May 19, 2021

Carbamazepine overdose

 Q: Which of the following drug has no role in the management of Carbamazepine acute toxicity?

A) sodium bicarbonate 

B) diazepam 

C) propofol 

D) phenytoin 

 E) activated charcoal

Answer: D

The major concern in Carbamazepine overdose is QRS interval prolongation leading to fatal arrhythmias. The treatment is sodium bicarbonate to keep QRS interval below 110 milliseconds (choice A).

Seizure secondary to carbamazepine is best treated with benzodiazepines and if frequent boluses of benzodiazepines are required, the patient should be intubated and started on continuous infusion of propofol (Choices B and C).

Phenytoin has no role in Carbamazepine-induced seizure (choice D).

Like any other acute pharmacological toxic ingestion activated charcoal should be utilized for gastrointestinal decontamination (choice E).



1. Spiller HA, Krenzelok EP, Cookson E. Carbamazepine overdose: a prospective study of serum levels and toxicity. J Toxicol Clin Toxicol. 1990;28(4):445-58. doi: 10.3109/15563659009038587. PMID: 2269999. 

2. Al Khalili Y, Sekhon S, Jain S. Carbamazepine Toxicity. 2021 Feb 15. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29939629.

Tuesday, May 18, 2021

vasospasm SAH

 Q: Which group of patients is more prone to have vasospasm after subarachnoid hemorrhage (SAH)? (select one)

A) less than 50 years of age

B) more than 50 years of age

Answer: A

The risk and the severity of vasospasm after SAH depends on the following factors 
  • severity of bleed 
  • proximity to the major intracerebral blood vessels
  • higher grade on Fisher and Claassen scales
  • age less than 50 years (due to higher capacity of vascular tone & elasticity)
  • hyperglycemia 
  • higher Glasgow coma scale score
Vasospasm follows SAH around day 3 and usually peaks at days 7 or 8. This lag is due to spasmogenic substances produced by the lysis of subarachnoid blood.



Charpentier C, Audibert G, Guillemin F, et al. Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage. Stroke 1999; 30:1402.

Monday, May 17, 2021

Rx postpartum thyroiditis

 Q: 32 years old female is admitted to ICU with urosepsis. She is also found to be in postpartum thyroiditis. Which should be the first line of treatment besides management for urosepsis? 

A) propranolol

B) methimazole

C) propylthiouracil

D) radiation

Answer: A

Direct anti-thyroid management including methimazole, propylthiouracil, and radiation has no value in postpartum thyroiditis, also known as destructive thyroiditis. The synthesis of T4 and T3 is actually decreased in contrast to other hyperthyroid states. Condition is usually self-limiting and requires only symptomatic treatment. 

Propranolol is highly plasma protein-bound. This gives the advantage of minimal concentration in breast milk, and is a choice of beta-blocker in postpartum females. 





1. Stagnaro-Green A. Postpartum thyroiditis. Best Pract Res Clin Endocrinol Metab. 2004 Jun;18(2):303-16. doi: 10.1016/j.beem.2004.03.008. PMID: 15157842. 

2. Beardmore KS, Morris JM, Gallery ED. Excretion of antihypertensive medication into human breast milk: a systematic review. Hypertens Pregnancy 2002; 21:85.

Sunday, May 16, 2021

Abdominal exam

  Q: During abdominal exam which step is preferred to be performed first? (select one)

A) Percussion 

 B) Palpation

Answer: A

Although there is no hard and fast rule in this regard, experts recommend starting an abdominal exam with gentle percussion. Palpation, particularly over the most tender area, may quickly lead to abdominal muscle guarding making further examination difficult on an unwilling patient. 

Gentle percussion will allow identifying mass or organomegaly with dullness, distended bowel with tympany, and ascites with shifting dullness. 

 If palpation is carried out first, it should be started from the quadrant with the least complaint to avoid abdominal rigidness.




Reuben A. Examination of the abdomen. Clin Liver Dis (Hoboken). 2016;7(6):143-150. Published 2016 Jun 28. doi:10.1002/cld.556

Saturday, May 15, 2021

polyarticular gout

 Q: 42 years old male is admitted to ICU with possible polyarticular septic arthritis. Subsequent workup turned it out to be gout instead of sepsis. Initial gout presentation can be polyarticular in which conditions?

Answer: In primary gout, the initial presentation is mostly uniarticular but polyarticular gout can happen in few conditions where hyperuricemia occurs. The two most prominent clinical situations are:

1. Myeloproliferative disorder or lymphoproliferative disorder. This was first described more than five decades ago.

2. Patients on immunosuppressant drugs such as cyclosporine or tacrolimus. Cyclosporine is more common than tacrolimus to cause polyarticular gout, and in few cases switching cyclosporine to tacrolimus may help. 

Another feature of polyarticular gout flare is its sequential or migratory nature. It may also occur in a cluster form i.e., involving adjacent joints, tendons, and bursas.



1. Yü TF. Secondary gout associated with myeloproliferative diseases. Arthritis Rheum 1965; 8:765.

2. Stamp L, Searle M, O'Donnell J, Chapman P. Gout in solid organ transplantation: a challenging clinical problem. Drugs. 2005;65(18):2593-611. doi: 10.2165/00003495-200565180-00004. PMID: 16392875.

Friday, May 14, 2021

vitamin k

 Q: Vitamin K absorption requires which organ to be properly functional? (select one)

A) Pancreas

B) Kidney


Answer: A

Once oral Vitamin K is taken its absorption requires three properly working functions:

  • pancreatic 
  • biliary 
  • fat absorption
Vitamin K is protein-bound as it reaches the intestine. Pancreatic enzymes in the small intestine through proteolytic action cleave vitamin K from protein. Once liberated, vitamin K solubilizes into mixed micelles by bile salts. These mixed micelles get absorbed into enterocytes, where they are incorporated into chylomicrons, facilitating absorption into the intestinal lymphatics and portal circulation.



1. Food and Nutrition Board of the Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2000). National Academies Press, Washington DC, 2000. p. 162-196 (Accessed on April 29, 2021)

Thursday, May 13, 2021

AA and cardiac temponade

 Q: Why the perforation of proximal ascending aorta can cause cardiac tamponade? 

Answer: This is due to the anatomic location of the aortic root and first 10 cm of the ascending aorta, which lies within the pericardium. 

This is a surgical emergency. Without an appropriate workup, proceeding to pericadiocentesis just on the basis of echocardiography is not a prudent thing to do. Sole pericardiocentesis should be avoided as it may instantly lead to death due to increase tear of the aorta. Clinical presentation and other radiological findings should be carried out if time permits otherwise emergent call to OR is needed.




1. Guo R, Feng YM, Wan D. Hemorrhagic cardiac tamponade complicated by acute type A aortic dissection: A case report with critical care ultrasound findings. Medicine (Baltimore). 2017;96(49):e8773. doi:10.1097/MD.0000000000008773 

2. Ryu, D.W., Lee, M.K. Cardiac tamponade associated with delayed ascending aortic perforation after blunt chest trauma: a case report. BMC Surg 17, 70 (2017).

Wednesday, May 12, 2021

PPI and magnesium

 Q: Use of proton pump inhibitor (PPI) in ICU may cause? (select one) 

A) hypomagnesemia 

B) hypermagnesemia

Answer: A

There are many reasons for hypomagnesemia in ICU. These include diarrhea, history of alcohol use, PPI use, and diuretics. Hypomagnesemia may lead to unexplained hypocalcemia or refractory hypokalemia. This may also cause cardiac arrhythmias and neuromuscular disturbances.




1. Florentin M, Elisaf MS. Proton pump inhibitor-induced hypomagnesemia: A new challenge. World J Nephrol. 2012;1(6):151-154. doi:10.5527/wjn.v1.i6.151

2. Semb S, Helgstrand F, Hjørne F, Bytzer P. Persistent severe hypomagnesemia caused by proton pump inhibitor resolved after laparoscopic fundoplication. World J Gastroenterol. 2017;23(37):6907-6910. doi:10.3748/wjg.v23.i37.6907

Tuesday, May 11, 2021

Glucagon adjuvant treatment

 Q: 52 years old female admitted to ICU with an intentional overdose of metoprolol. IV glucagon has been planned as an antidote. Which one adjuvant treatment may be helpful to counter the side effect of glucagon?

Answer: antiemetic 

Despite weak evidence,  glucagon is frequently getting used in beta-blockers overdose. Glucagon should be given as a slow bolus followed by a continuous infusion. Glucagon activates adenylate cyclase causing an increase in adenosine 3'-5'-cyclic monophosphate (cAMP). Elevations in cAMP increase the intracellular calcium which augments contractility. 

Glucagon is known to induce vomiting. It may be helpful to add an antiemetic like ondansetron.



1. Bailey B. Glucagon in beta-blocker and calcium channel blocker overdoses: a systematic review. J Toxicol Clin Toxicol 2003; 41:595. 

2. Boyd R, Ghosh A. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Glucagon for the treatment of symptomatic beta blocker overdose. Emerg Med J 2003; 20:266.

3. Ranganath L, Schaper F, Gama R, Morgan L. Mechanism of glucagon-induced nausea. Clin Endocrinol (Oxf). 1999 Aug;51(2):260-1. doi: 10.1046/j.1365-2265.1999.00845.x. PMID: 10469001.

Monday, May 10, 2021

ASA and ACE-I angioedema

 Q: Aspirin is a good adjuvant treatment for Angiotensin-Converting Enzyme Inhibitor (ACE-I) induced angioedema?

A) True

B) False

Answer: B

Aspirin and other nonsteroidal anti-inflammatory drugs (NSAID) are risk factors to increase the likelihood of angioedema in patients taking ACE-I. Other risk factors include: 

  • Age over 65 years 
  • Female gender 
  • Tobacco history
  • History of seasonal allergies 
  • Previous episodes of angioedema


1. Kostis JB, Kim HJ, Rusnak J, et al. Incidence and characteristics of angioedema associated with enalapril. Arch Intern Med 2005; 165:1637.

2. Banerji A, Clark S, Blanda M, et al. Multicenter study of patients with angiotensin-converting enzyme inhibitor-induced angioedema who present to the emergency department. Ann Allergy Asthma Immunol 2008; 100:327. 

3.Hoover T, Lippmann M, Grouzmann E, et al. Angiotensin converting enzyme inhibitor induced angio-oedema: a review of the pathophysiology and risk factors. Clin Exp Allergy 2010; 40:50.

Sunday, May 9, 2021

Ascites and SBP

 Q:  The removal of ascitic fluid helps in decreasing the odds of spontaneous bacterial peritonitis (SBP)? 

A) True

B) False

Answer: A

Removal of ascitic fluid turns ascitic fluid opsonins more concentrated. This decreases the odds of SBP. 

A less tense abdomen also protects against the development of cellulitis and abdominal wall hernia. There is also less risk of developing hydrothorax by decreasing the chances of diaphragmatic rupture. Another less known effect is reduced expenditure of energy to heat the ascitic fluid. 

 Above said, despite all these benefits, there is no solid evidence that it improves underlying mortality.




1. Runyon BA, Van Epps DE. Diuresis of cirrhotic ascites increases its opsonic activity and may help prevent spontaneous bacterial peritonitis. Hepatology 1986; 6:396. 

2. Runyon BA, Antillon MR, McHutchison JG. Diuresis increases ascitic fluid opsonic activity in patients who survive spontaneous bacterial peritonitis. J Hepatol 1992; 14:249. 

3. Dolz C, Raurich JM, Ibáñez J, et al. Ascites increases the resting energy expenditure in liver cirrhosis. Gastroenterology 1991; 100:738.

Saturday, May 8, 2021

palmar erythema

 Q: The palmar erythema in cirrhosis is more prominent on? (select one) 

A) thenar eminence 

B) hypothenar eminence

Answer: B

The objective of this question is to enhance the importance of astute physical exams at the bedside. The presence of palmar erythema helps to confirm the diagnosis. Cirrhosis is one of the diseases which presents a wide range of physical findings. Few dermatological signs in cirrhosis are popularly known as 'stigmata of cirrhosis', and include spider angioma, palmar erythema, and abdominal wall collaterals. The palmar erythema is usually blotchy and patchy. It is more prominent on the hypothenar eminence. This palmar erythema spares the center of the palm. These findings are relatively easily identifiable on fair skin patients. 

Palmar erythema can be present in other diseases besides cirrhosis including Wilson's disease, neoplasms, and diabetes. Pregnant patients may also develop it transiently. 




 1. Serrao R, Zirwas M, English JC. Palmar erythema. Am J Clin Dermatol. 2007;8(6):347-56. doi: 10.2165/00128071-200708060-00004. PMID: 18039017.

2. Kakehashi R, Watanabe S, Ikoma J, Suzuki S. [Clinical symptoms of patients with liver cirrhosis]. Nihon Rinsho. 1994 Jan;52(1):40-4. Japanese. PMID: 8114308.

Friday, May 7, 2021


 Q: Patients developing severe thrombosis after the COVID-19 vaccine should be treated with heparin?

A) True

B) False

Answer: B

Vaccine-induced thrombotic thrombocytopenia (VITT) has been reported after the COVID-19 vaccine, particularly after adenovirus-based COVID-19 vaccines. This condition should be treated as Heparin-Induced Thrombocytopenia (HIT). Although there is no exposure to heparin clinical behavior is the same. Moreover, there are reports that patients deteriorate after receiving heparin in VITT. In these patients, it would be prudent to do anticoagulation only with non-heparin agents. In severe cases, intravenous immune globulin (IVIG) should be considered early in the case. 

Another important aspect is to follow the fibrinogen level. if it is below 100, consideration should be given to transfuse via blood product or synthetic version of fibrinogen. Alike all HIT patients, platelet transfusions should be avoided unless the bleeding is life-threatening. A hematologist should be on board to guide these unfortunate complex patients.




1. Greinacher A, Thiele T, Warkentin TE, et al. Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination. N Engl J Med 2021. 

2. (Accessed on May 6, 2021). 

3. (Accessed on May 6, 2021).

Thursday, May 6, 2021

Insulin resistance in COVID

 Q: Insulin resistance in COVID-19 is found to correlate with inflammatory markers? 

A) True 

B) False 


One of the relatively less described subjects in hospitalized COVID-19 patients is cytokine-induced severe insulin resistance. This becomes even more important with the addition of dexamethasone in the treatment of the COVID-19. Moreover, the risk of hypoglycemia also becomes high as COVID-19 improves or nutritional status changes during hospitalization. This requires very close monitoring. Fortunately, insulin resistance is found to correlate with inflammatory markers of COVID-19, particularly IL-6. 

Or vice versa, insulin resistance itself can be a sign of poor outcome in COVID-19.




1. Wu L, Girgis CM, Cheung NW. COVID-19 and diabetes: Insulin requirements parallel illness severity in critically unwell patients. Clin Endocrinol (Oxf) 2020; 93:390.

2. Ren H, Yang Y, Wang F, et al. Association of the insulin resistance marker TyG index with the severity and mortality of COVID-19. Cardiovasc Diabetol 2020; 19:58.

Wednesday, May 5, 2021


 Q: Tramadol is frequently used in ICUs. It can cause respiratory depression?

A) Yes

B) No

Answer: A

Tramadol is a part of various post-operative protocols as an analgesic. Providers should be aware that it comes with some inherent risks like respiratory depression. It is available as intravenous injection, immediate-release, and extended-release tablets. In ICUs, its administration may concurrently occur with benzodiazepines or other CNS depressants. This can be potentially fatal in a non-intubated patient. Tramadol also increases the risk of seizures.

Staff should be instructed that tramadol tablet or capsule particularly extended-release should not be split, break, chew, crush, or dissolve. 




 1. Dhesi M, Maldonado KA, Maani CV. Tramadol. [Updated 2020 Aug 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:

2. Stamer UM, Stüber F, Muders T, Musshoff F. Respiratory depression with tramadol in a patient with renal impairment and CYP2D6 gene duplication. Anesth Analg. 2008 Sep;107(3):926-9. doi: 10.1213/ane.0b013e31817b796e. PMID: 18713907.

3. Minkowitz H, Leiman D, Lu L, et al. IV Tramadol - A New Treatment Option for Management of Post-Operative Pain in the US: An Open-Label, Single-Arm, Safety Trial Including Various Types of Surgery. J Pain Res. 2020;13:1155-1162. Published 2020 May 22. doi:10.2147/JPR.S251175

Tuesday, May 4, 2021

sch in pregnancy

 Q: Succinylcholine should be given to a pregnant patient depending on total body weight? 

A) True 

B) False 


Dose of succinylcholine is given based on total body weight. Interestingly, this is true for pregnant patients too. This is due to the fact that overestimation of the dose of succinylcholine causes the same level of paralysis. One of the caveat is that duration of action of succinylcholine is longer in pregnant women. Serum cholinesterase activity is 30% less in pregnant females and immediate postpartum females. 

Recommended dose in these patients is 1.0 mg/kg.





1. Guay J, Grenier Y, Varin F. Clinical pharmacokinetics of neuromuscular relaxants in pregnancy. Clin Pharmacokinet 1998; 34:483. 

2. Patanwala AE, Sakles JC. Effect of patient weight on first pass success and neuromuscular blocking agent dosing for rapid sequence intubation in the emergency department. Emerg Med J 2017; 34:739. 

3. Gyasi HK, Mohy O, Abu-Gyamphi, Naquib M. Plasma cholinesterase level in Pregnancy-effect of enzyme activity on the duration of action of succinylcholine. Middle East J Anesthesiol 1986;8:379-85. 

4. Leighton BL, Cheek TG, Gross JB, Apfelbaum JL, Shantz BB, Gutsche BB, et al. Succinylcholine pharmacodynamics in peripartum females Anesthesiology 1986;64:202-5 

5. Rasheed MA, Palaria U, Bhadani UK, Quadir A. Determination of optimal dose of succinylcholine to facilitate endotracheal intubation in pregnant females undergoing elective cesarean section. J Obstet Anaesth Crit Care 2012;2:86-91

Monday, May 3, 2021

Yersinia enterocolitica and blood disorder

 Q; 19 years old adolescent male with some kind of blood disorder (not known to his roommate) is brought to ICU from a college dorm with sepsis-like symptoms. Subsequent workup led to the diagnosis of yersiniosis. Patients with which blood disorder are more prone to have yersiniosis?  

Answer: Thalassemia

Yersinia is ferrophilic (iron-loving). Thalassemia patients frequently develop iron overload due to frequent blood transfusions. Said that patients with thalassemia can develop severe yersiniosis without very high iron load. The reason for this phenomenon is not understood. 

Other risk factors are undercooked/raw pork products, un-sanitized water, cirrhosis, hemochromatosis, aplastic anemia, thalassemia, malignancy, diabetes, malnutrition, and gastrointestinal illnesses.



Adamkiewicz TV, Berkovitch M, Krishnan C, et al. Infection due to Yersinia enterocolitica in a series of patients with beta-thalassemia: incidence and predisposing factors. Clin Infect Dis 1998; 27:1362.

Sunday, May 2, 2021


 Q: Doxycycline being a tetracycline needs to be adjusted in renal dysfunction? 

A) True 

B) False

Answer: B

This is true for most of the tetracyclines that they get eliminated via renal route and need adjustment in renal insufficiency. Doxycycline is one of the tetracyclines which gets 80 percent excreted in the feces via bile. Tigecycline is another tetracycline that does not require adjustment in the renal insufficiency. 

Tetracyclines are usually contraindicated in children due to their tendency to cause tooth discoloration and bony growth retardation. Doxycycline is one unique tetracycline that can be used in children less than eight years of age. Also it can be used in pregnant and breastfeeding females if required.



Vojtová V, Urbánek K. Farmakokinetika tetracyklinů a glycylcyklinů [Pharmacokinetics of tetracyclines and glycylcyclines]. Klin Mikrobiol Infekc Lek. 2009 Feb;15(1):17-21. Czech. PMID: 19399726.

Saturday, May 1, 2021

Sinus brady

Q; Which EKG findings confirm the sinus node origin of bradycardia (sinus bradycardia)?

Answer:  A quick glance at the following 2 findings on EKG confirm the sinus bradycardia
  • an upright P wave in leads I, II, and aVL, and 
  • a negative P wave in lead aVR
Although this is a very basic teaching pearl but an essential one to rule out other causes of bradyarrhythmia - a common scenario in ICU.



Kadish AH, Buxton AE, Kennedy HL, et al. ACC/AHA clinical competence statement on electrocardiography and ambulatory electrocardiography. A report of the ACC/AHA/ACP-ASIM Task Force on Clinical Competence (ACC/AHA Committee to Develop a Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography). J Am Coll Cardiol 2001; 38:2091.