Monday, June 14, 2021

Potassium and EKG changes

 Q: The progression of EKG changes correlate well with the serum potassium concentration?

A) Yes

B) No


Answer: B

There are several EKG changes that occur with hyperkalemia. In early phases, the most well-known is a tall peaked T wave. The less known fact is that it should be read with a shortened QT interval. This is followed by progressive lengthening of the PR interval along with QRS duration. The disappearance of P-wave is relatively a late sign. QRS continues to widen and become a sine wave. This quickly degenerates into asystole. 

Although above is the classic progress of EKG changes, hyperkalemia can be characterized by various other appearances on the EKG including bradycardia, idioventricular rhythms, V. Tach., V. Fib., pseudo-ST-elevations mimicking myocardial infarction, and pseudo-Brugada patterns. 

The most important thing to remember is that an EKG change in hyperkalemia is an urgency to treat, as they do not correlate well with the serum potassium level.

#cardiology


References:


1. Littmann L, Gibbs MA. Electrocardiographic manifestations of severe hyperkalemia. J Electrocardiol 2018; 51:814. 

2. Montague BT, Ouellette JR, Buller GK. Retrospective review of the frequency of ECG changes in hyperkalemia. Clin J Am Soc Nephrol. 2008 Mar;3(2):324-30. doi: 10.2215/CJN.04611007. Epub 2008 Jan 30. PMID: 18235147; PMCID: PMC2390954.

3. Durfey N, Lehnhof B, Bergeson A, et al. Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?. West J Emerg Med. 2017;18(5):963-971. doi:10.5811/westjem.2017.6.33033

Sunday, June 13, 2021

Acyclovir side effect

 Q: 44 years old male with End-Stage Renal Failure (ESRD) on chronic peritoneal dialysis is admitted to ICU with Herpes pneumonia and started on acyclovir. Patient progressively developed agitation, delirium and went into coma. Patients on peritoneal dialysis have higher risk of acyclovir toxicity?

A) True

B) False


Answer: A

When it comes to Acyclovir two considerations are very important. First, acyclovir itself can cause Acute Kidney Injury (AKI) by precipitating relatively insoluble acyclovir crystals in the renal tubules. This risk is high with intravenous (IV) route and can be eliminated by reducing the dose and prior high hydration with urine output around 75-100 cc/hr. This can be challenging in cardiac or renal patients, not on dialysis yet. 

When it comes to patients already on dialysis, peritoneal dialysis is not very effective in the removal of acyclovir. This is due to the fact that the drug is not highly bound to plasma protein. It quickly penetrates tissue and fluid including cerebrospinal fluid (CSF). A nephrologist and a pharmacist should be consulted to avoid this dreaded complication.


#pharmacology


References:

1. Heintz BH, Matzke GR, Dager WE. Antimicrobial dosing concepts and recommendations for critically ill adult patients receiving continuous renal replacement therapy or intermittent hemodialysis. Pharmacotherapy 2009; 29:562. 

2. Patel J, Hayes B, Bauler L, Mastenbrook J. Neurologic Acyclovir Toxicity in the Absence of Kidney Injury. J Emerg Med 2019; 57:e35. 

3. Gentry JL 3rd, Peterson C. Death Delusions and Myoclonus: Acyclovir Toxicity. Am J Med 2015; 128:692. 

4. Davenport A, Goel S, Mackenzie JC. Neurotoxicity of acyclovir in patients with end-stage renal failure treated with continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1992; 20:647. 

5. Stathoulopoulou F, Almond MK, Dhillon S, Raftery MJ. Clinical pharmacokinetics of oral acyclovir in patients on continuous ambulatory peritoneal dialysis. Nephron 1996; 74:337.

Saturday, June 12, 2021

GAP in IPF

 Q: 64 years old male who has never had access to any healthcare, admitted to ICU with severe hypoxemia. Subsequent workup led to diagnosis of idiopathic lung fibrosis (IPF). Pulmonology service starts to calculate the GAP model.  The GAP stands for? (select one)

A) Gene-Age-Physiology model 

B) Gender-Age-Physiology model

C) Graded-Age-Physiology model

D) Guided-Age-Physiology model

E) Goal-directed-Age-Physiology model


Answer: B

GAP is a validated clinical prediction model for patients with IPF to predict 1, 2, and 3-year mortality. The calculator takes into account - gender, age, predicted Forced Vital Capacity (FVC) and predicted diffusing capacity of the lungs for carbon monoxide (DLCO). Once combined with functional status, patient wishes, and other clinical conditions it helps to decide on the aggressiveness of treatment ranging from lung transplant to palliation.

The calculator is simple to use and can be viewed at  https://www.acponline.org/journals/annals/extras/gap/


# pulmonary

#transplantations


References:

1. Ley B, Ryerson CJ, Vittinghoff E, Ryu JH, Tomassetti S, Lee JS, Poletti V, Buccioli M, Elicker BM, Jones KD, King TE Jr, Collard HR. A multidimensional index and staging system for idiopathic pulmonary fibrosis. Ann Intern Med. 2012 May 15;156(10):684-91. doi: 10.7326/0003-4819-156-10-201205150-00004. PMID: 22586007.

2. Lee SH, Kim SY, Kim DS, Kim YW, Chung MP, Uh ST, Park CS, Jeong SH, Park YB, Lee HL, Shin JW, Lee EJ, Lee JH, Jegal Y, Lee HK, Kim YH, Song JW, Park SW, Park MS. Predicting survival of patients with idiopathic pulmonary fibrosis using GAP score: a nationwide cohort study. Respir Res. 2016 Oct 18;17(1):131. doi: 10.1186/s12931-016-0454-0. PMID: 27756398; PMCID: PMC5069824.

Friday, June 11, 2021

panniculitis

 Q: In acute pancreatitis - panniculitis are most commonly found at? (select one) 

A) Chest area 

B) Flank area 

C) Upper extremities 

D) Lower extremities 

E) Perineal area 


 Answer: D

Physical exam particularly cutaneous exam can be of profound help in acute pancreatitis. 

Panniculitis are actually subcutaneous nodular fat necrosis lesions which are tender to touch and appears as reddish nodules. They are commonly found in distal areas of lower extremities, though may be present at other places in the body. 

Two other significant cutaneous findings are Cullen's sign and Grey Turner sign. Cullen's sign is ecchymotic discoloration in the periumbilical region and Grey Turner sign is ecchymotic discoloration mostly along the flanks. These two signs are due to retroperitoneal bleed subsequent to pancreatic necrosis. 

Besides above, other cutaneous findings can also be of help such as xanthomas in hyperlipidemic pancreatitis.


#physical-exam

#GI


References:

1.  Dahl PR, Su WP, Cullimore KC, Dicken CH. Pancreatic panniculitis. J Am Acad Dermatol 1995; 33:413. 

2. Bennett RG, Petrozzi JW. Nodular subcutaneous fat necrosis. A manifestation of silent pancreatitis. Arch Dermatol 1975; 111:896.

3. Mookadam F, Cikes M. Images in clinical medicine. Cullen's and Turner's signs. N Engl J Med 2005; 353:1386.

Thursday, June 10, 2021

bell and the diaphragm of the stethoscope

Q:  The diaphragm of the stethoscope detects best? (select one) 

A) high-frequency sounds 

B) low-frequency sounds


Answer: A

The stethoscope has two heads: Bell and Diaphragm - 

  • Bell is best to detect low-frequency sounds like third and fourth heart sounds 
  • Diaphragm is best to detect high-frequency sounds like pericardial and pleural friction rubs

#physical-exam


References:

1. Murphy RL. In defense of the stethoscope. Respir Care. 2008 Mar;53(3):355-69. PMID: 18291053. 

2. David L, Dumitrascu DL. The bicentennial of the stethoscope: a reappraisal. Clujul Med. 2017;90(3):361-363. doi:10.15386/cjmed-821 

3. O'Neill D. Using a stethoscope in clinical practice in the acute sector. Prof Nurse. 2003 Mar;18(7):391-4. PMID: 12674046.

Wednesday, June 9, 2021

SBO grading

 Q: There are how many grades of Small Bowel Obstruction (SBO)? (select one)

A) Minimum, Moderate and Severe

B) 1, 11, and 111

C) 1, 11, 111, 1V, and V


Answer: C

The American Association for the Surgery of Trauma (AAST) has developed a grading system for SBO taking into consideration the radiological and operative criteria. It has been validated as reliable in subsequent studies. Higher grading predicts at least three things 

  • Higher hospital Length of Stay (LOS) 
  • Higher ICU LOS, and 
  • Higher complications.



#surgical-critical-care


Reference:

1. Hernandez MC, Haddad NN, Cullinane DC, Yeh DD, Wydo S, Inaba K, Duane TM, Pakula A, Skinner R, Rodriguez CJ, Dunn J, Sams VG, Zielinski MD, Choudhry A, Turay D, Yune JM, Watras J, Widom KA, Cull J, Toschlog EA, Graybill JC; EAST SBO Workgroup. The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction. J Trauma Acute Care Surg. 2018 Feb;84(2):372-378. doi: 10.1097/TA.0000000000001736. PMID: 29117026.

Tuesday, June 8, 2021

strategies to decrease steroids side effects

 Q: Locally acting glucocorticoids have a lesser risk of superimposed infections than systemic glucocorticoids? 

 A) True 

B) False 


Answer: A

There are various strategies to reduce the risk of superimposed infections. Some of the strategies which can be considered are:

1. Applying glucocorticoids directly to the area/system which is targeted such as a nebulizer or inhaler for respiratory disease, or an oral steroid with high, first-pass metabolism like budesonide for intestinal inflammation. 

2. Alternate-day dosing if clinically appropriate. Prednisone effect may last up to 36 hours, and dexamethasone effect may last up to 72 hours.

3. Early mobilization and physical therapy to counter myopathy. 

#pharmacology


References:

1. Fauci AS, Dale DC, Balow JE. Glucocorticosteroid therapy: mechanisms of action and clinical considerations. Ann Intern Med 1976; 84:304.

Monday, June 7, 2021

NCT

 Q: Number connection test (NCT), also known as Reitan Test is used to evaluate which pathology? 

 Answer: Hepatic encephalopathy

NCT (Reitan Test) is a timed connect-the-numbers test. With no underlying hepatic encephalopathy, patients finish the test in seconds less than or equal to their age in years. If a patient is 40 years of age, he should finish the test in less than or in 40 seconds. Another rule of thumb described is that any healthy person should be able to finish in 30 seconds. 

Test was invented to administered in two-four parts but subsequent experience found that only one part is as effective as complete test.

Details can be found at:

 https://anthc.org/wp-content/uploads/2017/05/Numbers-Connection-Test.pdf


#hepatology


References:

1. Conn HO. Trailmaking and number-connection tests in the assessment of mental state in portal systemic encephalopathy. Am J Dig Dis 1977; 22:541. 

2. Amodio P, Del Piccolo F, Marchetti P, et al. Clinical features and survivial of cirrhotic patients with subclinical cognitive alterations detected by the number connection test and computerized psychometric tests. Hepatology 1999; 29:1662.

3. Weissenborn K, Rückert N, Hecker H, Manns MP. The number connection tests A and B: interindividual variability and use for the assessment of early hepatic encephalopathy. J Hepatol 1998; 28:646.

Sunday, June 6, 2021

Lugol's solution - routes of administration

 Q: 22 years old female is admitted to ICU with thyroid storm. Iodine solution is planned to be administered. Patient is having severe nausea and may not tolerate oral intake. Can it be given intravenously?

A) Yes

B) No


Answer: A

In a thyroid storm, iodine should be planned to be administered an hour after the first dose of thionamide. Iodine is mostly available as a potassium iodide-iodine solution, popularly known as Lugol's solution. The standard dose is 10 drops. If a patient cannot tolerate oral intake it can be added to intravenous fluid (IVF). Moreover, iodine may cause esophageal or duodenal mucosal damage leading to bleeding and should be diluted in a beverage or given with food. 

The iodine solution can also be administrated rectally.


#endocrinology


References:

1. Benua RS, Becker DV, Hurley JR. Thyroid storm. In: Current Therapy in Endocrinology and Metabolism, Bardin CW (Ed), Mosby, St. Louis 1994. p.75.

2. Yeung SC, Go R, Balasubramanyam A. Rectal administration of iodide and propylthiouracil in the treatment of thyroid storm. Thyroid 1995; 5:403.

Saturday, June 5, 2021

HBO in CO

 Q: What are the indications for hyperbaric oxygen in carbon mono-oxide (CO) poisoning?

Answer: There are two major interventions required in the acute management of CO poisoning.

  1. Removal of the source
  2. Oxygen

Hyperbaric oxygen if available should be considered in the following situations:

  • CO level >25% 
  • CO level >20% in pregnant patients 
  • Loss of consciousness 
  • PH less than 7.1 by arterial blood gas (ABG) 
  • End-organ ischemia evident by EKG changes, chest pain, encephalopathy, and others
#toxicology



References:

1. Ernst A, Zibrak JD. Carbon monoxide poisoning. N Engl J Med 1998; 339:1603. 

2. Hampson NB, Dunford RG, Kramer CC, Norkool DM. Selection criteria utilized for hyperbaric oxygen treatment of carbon monoxide poisoning. J Emerg Med 1995; 13:227. 

3. Huang CC, Ho CH, Chen YC, et al. Hyperbaric Oxygen Therapy Is Associated With Lower Short- and Long-Term Mortality in Patients With Carbon Monoxide Poisoning. Chest 2017; 152:943.

4. Elkharrat D, Raphael JC, Korach JM, et al. Acute carbon monoxide intoxication and hyperbaric oxygen in pregnancy. Intensive Care Med 1991; 17:289.

Friday, June 4, 2021

Dapto in MRSA CNS infections

 Q: Daptomycin is a good alternative to vancomycin if required to use in MRSA meningitis?

A) True

B) False


Answer: B

Daptomycin has no role in Central Nervous System (CNS) infections. It has very poor penetration into the cerebrospinal fluid (CSF). This is due to two reasons. First, it has a high molecular mass, and second, it is highly protein-bound. Unlike other drugs, meningeal inflammation does not increase its CSF penetration. 

Also, it is not a good choice in pneumonia as it gets inactivated by alveolar surfactants. It has its the best value in skin and soft tissue infections with Methicillin-resistant Staphylococcus aureus (MRSA).

#ID


References:

1. Piva S, Di Paolo A, Galeotti L, et al. Daptomycin Plasma and CSF Levels in Patients with Healthcare-Associated Meningitis. Neurocrit Care 2019; 31:116. 

2. Kullar R, Chin JN, Edwards DJ, et al. Pharmacokinetics of single-dose daptomycin in patients with suspected or confirmed neurological infections. Antimicrob Agents Chemother 2011; 55:3505. 

3. Silverman JA, Mortin LI, Vanpraagh AD, et al. Inhibition of daptomycin by pulmonary surfactant: in vitro modeling and clinical impact. J Infect Dis 2005; 191:2149.

Thursday, June 3, 2021

HH

 Case: 33 years old male with no past medical history is admitted to ICU with Diabetes Ketoacidosis (DKA). On examination, he is found to have skin hyperpigmentation and pedal edema. Labs were remarkable for severe transaminitis. Patient reports overuse of elements and vitamins. The presumptive diagnosis of  Hereditary Hemochromatosis (HH) is made on the basis of family history and further lab testing. Out of the following which diagnostic test should be ordered next? (select one)

A) Echocardiogram

B) Liver biopsy


Answer: A

Hereditary Hemochromatosis (HH) is the most common genetic disorder in the world. This is due to the mutations in the HH gene known as HFEThis leads to increased intestinal iron absorption and total-body iron overload. In recent years over ingestion of over-the-counter vitamins became a concern for more symptomatic presentations for these patients.

A liver biopsy is not required for the diagnosis of HH. Estimation by MRI for iron stores can be done in the majority of the patients. Echocardiography should be done as cardiac iron overload may lead to dilated cardiomyopathy, as evident in our patient with pedal edema.

DKA can be a presenting symptom due to pancreatic infiltration.

#endocrinology

#hepatology

#cardiology

#metabolism


References:

1. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 31-1994. A 25-year-old man with the recent onset of diabetes mellitus and congestive heart failure. N Engl J Med 1994; 331:460. 

2. Raju K, Venkataramappa SM. Primary Hemochromatosis Presenting as Type 2 Diabetes Mellitus: A Case Report with Review of Literature. Int J Appl Basic Med Res. 2018;8(1):57-60. doi:10.4103/ijabmr.IJABMR_402_16 

3. Bacon BR, Adams PC, Kowdley KV, Powell LW, Tavill AS; American Association for the Study of Liver Diseases. Diagnosis and management of hemochromatosis: 2011 practice guideline by the American Association for the Study of Liver Diseases. Hepatology. 2011 Jul;54(1):328-43. doi: 10.1002/hep.24330. PMID: 21452290; PMCID: PMC3149125.

Wednesday, June 2, 2021

Erythromycin site of action as a motility agent

 Q: Erythromycin is frequently used in ICU as a motility agent. Which part of the stomach it works upon? (select one)

A) cardia

B) fundus

C) body

D) pyloric antrum

E) pyloric canal


Answer: B

Erythromycin is frequently used as a motility agent in ICU as it is a motilin agonist. It works mostly in the stomach as a gastric emptying agent by inducing high-amplitude gastric propulsive contractions. It works mostly at the fundus region which helps in suppressing the fundus' accommodative response after the enteral feed. The lowest starting dose should be used i.e., 40 mg prior to a meal or three times a day to avoid tachyphylaxis which may occur quickly with 250 mg dose three times a day. 

Some institutions follow a proper algorithm for gastroparesis.

#GI


References:

1. Keshavarzian A, Isaac RM. Erythromycin accelerates gastric emptying of indigestible solids and transpyloric migration of the tip of an enteral feeding tube in fasting and fed states. Am J Gastroenterol 1993; 88:193. 

2. Camilleri M. Clinical practice. Diabetic gastroparesis. N Engl J Med 2007; 356:820.

Tuesday, June 1, 2021

Quinolones side effects

 Q: Name at least five side effects of fluoroquinolone that should be kept in mind for ICU/hospitalized patients? 

Answer:

1. prolong QTc interval which may become fatal with electrolyte abnormalities and concomitant use of other drugs causing QTc prolongation

2. increased risk of aortic aneurysm and dissection - this risk may persist for about eight weeks after use. It should be avoided in elderly patients with such a history or with severe vascular diseases such as Marfan syndrome

3. malregulation of glucose level causing hyper and/or hypoglycemia

4. increased risk of CNS effects including seizures, increased intracranial pressure (pseudotumor cerebri), lightheadedness, and tremors

5. increased risk of peripheral neuropathy - we included this side effect here as this can be irreversible

6. increased risk of psychiatric issues such as toxic psychosis, hallucinations, paranoia, agitation, restlessness, delirium, insomnia, anxiety, memory impairment, confusion, depression, and suicidal thoughts

7. increased risk of tendinopathy in patients on chronic steroid, renal insufficiency or solid organ transplant recipients


#pharmacology


References:

1. Stahlmann R, Lode H. Toxicity of quinolones. Drugs. 1999;58 Suppl 2:37-42. doi: 10.2165/00003495-199958002-00007. PMID: 10553703.

2. Friedrich LV and Dougherty R, “Fatal Hypoglycemia Associated With Levofloxacin,” Pharmacotherapy, 2004, 24(12):1807-12.

3. Khaliq Y and Zhanel GG. Fluoroquinolone-Associated Tendinopathy: A Critical Review of the Literature. Clin Infect Dis. 2003;36(11):1404-1410

4. Lawrence KR, Adra M, Keir C. Hypoglycemia-Induced Anoxic Brain Injury Possibly Associated With Levofloxacin. J Infect. 2006;52(6):e177-e180.

5. Lee CC, Lee MG, Hsieh R, et al. Oral fluoroquinolone and the risk of aortic dissection. J Am Coll Cardiol. 2018;72(12):1369-1378. doi: 10.1016/j.jacc.2018.06.067