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.