Eye in ICU

Case: 32 years old male was admitted with COVID pneumonia which required intubation, sedation, neuro-muscular blockade (NMB), and pronation is now extubated but complaining of foreign body sensation in the right eye and photophobia. On clinical exam found to have some ciliary flush. Your next step? (select one)

A) observation

B) saline drops

C) ophthalmic antibiotics

D) urgent ophthalmology consult

Answer: D

One of the usually neglected portions is ophthalmic care in ICU, particularly in high-risk patients. Many patients who require (NMB) may not be able to close their eyes fully despite full sedation. Pronation also increases intra-ocular pressure. Ciliary flush is an emergent clinical consult as there may be underlying infectious keratitis, iritis, or angle-closure glaucoma. Other emergent ophthalmic consults are:

• Decrease visual acuity
• Photophobia 
• Severe foreign body sensation (patient can't keep an eye open)
• Corneal opacity 
• Fixed pupil 
• Severe headache with nausea
• Concern for hyperacute bacterial conjunctivitis 
• Concern for corneal abrasion

#opthalmology

References:

1. Cheung CA, Rogers-Martel M, Golas L, Chepurny A, Martel JB, Martel JR. Hospital-based ocular emergencies: epidemiology, treatment, and visual outcomes. Am J Emerg Med. 2014 Mar;32(3):221-4. doi: 10.1016/j.ajem.2013.11.015. Epub 2013 Nov 14. PMID: 24418441.

2. Gilani CJ, Yang A, Yonkers M, Boysen-Osborn M. Differentiating Urgent and Emergent Causes of Acute Red Eye for the Emergency Physician. West J Emerg Med. 2017 Apr;18(3):509-517. doi: 10.5811/westjem.2016.12.31798. Epub 2017 Mar 3. PMID: 28435504; PMCID: PMC5391903.

PVTT in HCC

Q: The finding of portal vein tumor thrombus(PVTT) in patients with Hepatocellular carcinoma (HCC) is a good prognostic sign as it signifies en masse total resectability?

A) True

B) False

Answer: B

PVTT is a macrovascular invasion in HCC and is a poor prognostic sign. It leads to major complications such as worsening liver function, metastatic disease, portal hypertension, and intolerance for treatment. It has been staged in five categories, Vp3 or Vp4 goes only for supportive care as survival is barely 8-16 weeks.

• Vp0 – No tumor thrombus in the portal vein;
• Vp1 – Segmental tumor thrombus distal to the second-order branches of the portal vein without direct involvement
• Vp2 – Invasion of a second order (right anterior or posterior, left anterior or posterior) branch of the portal vein
• Vp3 – Presence of the tumor thrombus in a first-order (right or left lobar) branch of the portal vein
• Vp4 – Tumor thrombus in the main trunk of the portal vein or a portal vein branch that is contralateral to the primarily involved lobe (or both)

#hepatology

#oncology

References:

1. Mähringer-Kunz A, Steinle V, Kloeckner R, et al. The impact of portal vein tumor thrombosis on survival in patients with hepatocellular carcinoma treated with different therapies: A cohort study. PLoS One 2021; 16:e0249426.

2. Khan AR, Wei X, Xu X. Portal Vein Tumor Thrombosis and Hepatocellular Carcinoma - The Changing Tides. J Hepatocell Carcinoma 2021; 8:1089.

3. Mähringer-Kunz A, Steinle V, Düber C, et al. Extent of portal vein tumour thrombosis in patients with hepatocellular carcinoma: The more, the worse? Liver Int 2019; 39:324.

RSBI

Q: If Rapid Shallow Breathing Index (RSBI) is measured while a patient is attached to the ventilator, respiratory rate should be counted? (select one)

A) manually

B) sensed by ventilator

Answer: A

One of the common mistakes clinicians make while measuring RSBI is to read the respiratory rate from the ventilator. The RSBI formula is simple: Respiratory Rate (f) divided by Tidal Volume in Litres. 

RSBI = f/TV(L)

Ideally, RSBI should be measured via a hand-held spirometer attached to the endotracheal tube (ETT) while the patient breathes room air for one minute - which means no ventilator assistance. 

In the real world, RSBI is usually obtained while a patient is attached to a ventilator. In such cases, the ventilator should be switched to a pressure support (PS) of 0 cm H2O and a positive end-expiratory pressure (PEEP) of 0 cm H2O, without flow or pressure trigger for one minute. 

Although tidal volume can be measured from the ventilator, the respiratory rate should be manually counted as the ventilator underestimate the respiratory rate. If a patient's inspiratory effort is not sensed by the ventilator, it will not be registered by the machine, but a clinician will sense it. This is a common scenario in patients with COPD. This will give falsely 'passed' RSBI and potentially may require re-intubation.

#ventilators

References:

1. Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med 1991; 324:1445.

2. El-Khatib MF, Zeineldine SM, Jamaleddine GW. Effect of pressure support ventilation and positive end expiratory pressure on the rapid shallow breathing index in intensive care unit patients. Intensive Care Med 2008; 34:505.

3. Patel KN, Ganatra KD, Bates JH, Young MP. Variation in the rapid shallow breathing index associated with common measurement techniques and conditions. Respir Care 2009; 54:1462.

4. Desai NR, Myers L, Simeone F. Comparison of 3 different methods used to measure the rapid shallow breathing index. J Crit Care 2012; 27:418.e1.

VIR and opioid

Q: The intensity of Vancomycin Infusion Reaction (VIR) (Red Man Syndrome) can be minimized by concomitant administration of opioids?

A) True

B) False

Answer; B

VIR, popularly known as 'Red Man Syndrome'*, is a phenomenon that is described as an idiopathic reaction if Vancomycin is infused too fast. This believes to occur due to mast cell activation. Few drugs can enhance this reaction and should not be given concurrently with IV vancomycin. This includes opioids which are known to enhance dose- or rate-related mast cell degranulation. Also, radiocontrast dye and muscle relaxants are known to cause it. If needed, antihistamines should be given to decrease VIR or drug-drug-enhanced VIR.

The best prevention is to dilute and slow the infusion of the drug. A gram of vancomycin should be administered over about 2 hours.

*Red Man Syndrome is a derogatory term and should be avoided.

#pharmacology

References:

1. Renz CL, Thurn JD, Finn HA, et al. Oral antihistamines reduce the side effects from rapid vancomycin infusion. Anesth Analg 1998; 87:681.

2. Polk RE, Healy DP, Schwartz LB, et al. Vancomycin and the red-man syndrome: pharmacodynamics of histamine release. J Infect Dis 1988; 157:502.

3. Wong JT, Ripple RE, MacLean JA, et al. Vancomycin hypersensitivity: synergism with narcotics and "desensitization" by a rapid continuous intravenous protocol. J Allergy Clin Immunol 1994; 94:189.

proteinuria autosomal dominant polycystic kidney disease

Q: Proteinuria is the earliest feature of so far undiagnosed autosomal dominant polycystic kidney disease (ADPKD)?

A) True

B) False

Answer: B

Unlike other major causes of renal failure, proteinuria is not a remarkable feature of ADPKD. It occurs late in the course. If nephrotic syndrome type picture emerges in a patient with ADPKD, it signifies a superimposed glomerular disease. 

ADPKD occurs slow and major signs and symptoms (S/S) include progressive enlargement of the renal cysts. In fact, measured total kidney volume is considered the strongest predictor of the impending renal failure. Other S/S  may be hypertension, frequent urinary tract infections, gross hematuria, kidney stones, and acute and/or chronic flank/abdominal pain.

#nephrology

References:

1. Chapman AB, Bost JE, Torres VE, et al. Kidney volume and functional outcomes in autosomal dominant polycystic kidney disease. Clin J Am Soc Nephrol 2012; 7:479.

2. Chapman AB, Johnson AM, Gabow PA, Schrier RW. Overt proteinuria and microalbuminuria in autosomal dominant polycystic kidney disease. J Am Soc Nephrol 1994; 5:1349.

A note on Aortic Arch calcification

Case: 46 years old male is admitted to ICU with a motor vehicle accident (MVA) for observation. Before discharging to the floor, the morning CXR was negative except for evidence of the calcification of the aortic arch out of his age proportion.

Answer: Calcification of the aortic arch is found to be associated with a higher risk of cardiovascular diseases and also associated with overall increased mortality. In a massive study of almost 140,000 patients who were followed for a median of 28 years, aortic arch calcification was found to have a relative risk [RR] of 1.3 in men and 1.2 in women for coronary heart disease (CHD). Also, this study found a 1.5-fold increased risk of ischemic stroke in women.

#cardiology

#radiology

Reference:

Iribarren C, Sidney S, Sternfeld B, Browner WS. Calcification of the aortic arch: risk factors and association with coronary heart disease, stroke, and peripheral vascular disease. JAMA 2000; 283:2810.

Internal fistulas in diverticular disease

Q: Which of the following is the most common fistula formation as one of the complications of diverticulitis? (select one)

A) colovesical 

B) colovaginal  

C) coloenteric 

D) colocutaneous 

Answer: A 

Fistula formation is one of the dreaded complications of diverticulitis, which usually requires surgical management. In about a quarter of the patients who require surgery for diverticular disease, fistulas are found.  Most of the fistulas are formed from diverticulitis in the sigmoid colon. 65% of the time, it is colovesical fistulas, followed by colovaginal. Other fistulas are coloenteric, colouterine, and colocutaneous. In rare cases, it can be multiple.

#surgical-critical-care

References:

1. Woods RJ, Lavery IC, Fazio VW, et al. Internal fistulas in diverticular disease. Dis Colon Rectum 1988; 31:591.

2. Di Buono G, Bonventre G, Buscemi S, Randisi B, Romano G, Agrusa A. The colovescical fistula in diverticular disease: Laparoscopic approach in two different cases. Int J Surg Case Rep. 2020;77S(Suppl):S112-S115. doi: 10.1016/j.ijscr.2020.09.044. Epub 2020 Sep 11. PMID: 32972892; PMCID: PMC7876919.

3. Wassef R, Morgan S, Tassé D, Bernard D. Les fistules dans la maladie diverticulaire du côlon: étude de 29 cas [Fistulas in diverticular disease of the colon: study of 29 cases]. Can J Surg. 1983 Nov;26(6):546-9. French. PMID: 6627148.

sulfhemoglobinemia

Q: The antidote for Sulfhemoglobinemia is methylene blue?

A) True

B) False

Answer: B

Relatively less known than methemoglobinemia, sulfhemoglobinemia can also occur with oxidizing drugs such as dapsone, sulfonamides, metoclopramide, and nitrate. It shifts the hemoglobin-oxygen dissociation curve to the right, which means it deloads oxygen to the tissues easily and is not as harmful as methemoglobinemia. But, it falsely reduces the SpO2 alike methemoglobin, and can deceive clinicians. Also, to make diagnosis difficult, multi-wavelength co-oximetry can not distinguish it from methemoglobin well. It requires specialized biochemical testing. 

Diagnosis is via discontinuation of suspected offending drugs, and if there is no response to methylene blue.

#hematology

References:

1. Lu HC, Shih RD, Marcus S, et al. Pseudomethemoglobinemia: a case report and review of sulfhemoglobinemia. Arch Pediatr Adolesc Med 1998; 152:803.

2. Aravindhan N, Chisholm DG. Sulfhemoglobinemia presenting as pulse oximetry desaturation. Anesthesiology 2000; 93:883.

AV blocks in Lyme carditis

Q: 34 years old female, diagnosed with Lyme's disease 2 weeks ago, is now in the local rural ED of Wisconsin with a syncopal episode. EKG showed a third-degree AV block. ED physician inserted a temporary pacemaker and transferred patient to the tertiary care center. Cardiology is consulted in CCU. Cardiology service should strongly consider the insertion of a permanent pacemaker?

A) True

B) False

Answer: B

Atrioventricular (AV) block due to Lyme disease is typically short-lived and does not require a permanent pacemaker. In most cases, antimicrobial therapy is sufficient in Lyme carditis, but patients who develop syncope, dyspnea, or chest pain or have second- or third-degree atrioventricular block, or a marked prolonged PR interval, or any arrhythmias may require a temporary pacemaker. The choice of antibiotics includes doxycycline, amoxicillin, or cefuroxime.

#cardiology

#ID

References:

1. Lantos PM, Rumbaugh J, Bockenstedt LK, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clin Infect Dis 2021; 72:e1.

2. Lórincz I, Lakos A, Kovács P, et al. Temporary pacing in complete heart block due to Lyme disease: a case report. Pacing Clin Electrophysiol 1989; 12:1433.

ISCLS (Clarkson's disease or syndrome)

Q: What is the triad of Idiopathic systemic capillary leak syndrome (ISCLS)?

Answer: Idiopathic systemic capillary leak syndrome (ISCLS) consists of episodes of 

• severe hypotension 
• hypoalbuminemia, and 
• hemoconcentration 

Two important distinctions in this regard are important. First, patients are prone to episodes/attacks of profound derangements of the vascular endothelium with leakage of plasma and proteins into the interstitial compartment. Second, performing differential diagnoses with similar pathologic diseases is extremely important such as:

• Severe sepsis or septic shock 
• Recurrent toxic shock syndrome in women
• Anaphylaxis 
• Anaphylactic attacks of systemic mastocytosis
• Drug reactions
• Hereditary angioedema 

It is also called Clarkson's disease or syndrome.

#vascular

References:

1. CLARKSON B, THOMPSON D, HORWITH M, LUCKEY EH. Cyclical edema and shock due to increased capillary permeability. Am J Med 1960; 29:193.

2. Marks J, Shuster S. Disorders of capillary permeability. Br J Dermatol 1973; 88:619.

3. Gousseff M, Arnaud L, Lambert M, et al. The systemic capillary leak syndrome: a case series of 28 patients from a European registry. Ann Intern Med 2011; 154:464.

4. Druey KM, Parikh SM. Idiopathic systemic capillary leak syndrome (Clarkson disease). J Allergy Clin Immunol 2017; 140:663.

XPN

 Q: 42 years old male with a past medical history of kidney transplant is admitted to ICU with septic shock due to an underlying kidney infection. Patient gets diagnosed with xanthogranulomatous pyelonephritis (XPN). Broad-spectrum antibiotics started. Surgical service should be consulted for en-bloc nephrectomy?

A) True

B) False

Answer: A

Xanthogranulomatous pyelonephritis is usually unilateral and results in massive kidney destruction, except in the pediatric population, where it can be localized. Antibiotics are indicated due to infectious processes, but most patients need en-bloc nephrectomy, where fistula formations may also require repair. 

Pediatric patients with localized disease may get away with partial nephrectomy. Rarely, in some adult patients who develop bilateral disease, a surgeon may decide to avoid full nephrectomies to preserve kidney function.

XPN may confuse clinicians on bedside ultrasound as renal cell carcinoma. It is called Xanthogranulomatous pyelonephritis because, microscopically, there are granulomas and lipid-laden macrophages (hence the term xantho = yellow). 

#surgical-critical-care

#ID

#nephrology

References:

1. Parsons MA, Harris SC, Longstaff AJ, Grainger RG. Xanthogranulomatous pyelonephritis: a pathological, clinical and aetiological analysis of 87 cases. Diagn Histopathol 1983; 6:203. 

2. Peréz LM, Thrasher JB, Anderson EE. Successful management of bilateral xanthogranulomatous pyelonephritis by bilateral partial nephrectomy. J Urol 1993; 149:100. 

3. Guzzo TJ, Bivalacqua TJ, Pierorazio PM, et al. Xanthogranulomatous pyelonephritis: presentation and management in the era of laparoscopy. BJU Int 2009; 104:1265.

4. Parsons MA, Harris SC, Grainger RG, et al. Fistula and sinus formation in xanthogranulomatous pyelonephritis. A clinicopathological review and report of four cases. Br J Urol 1986; 58:488. 

5. Hitti W, Drachenberg C, Cooper M, et al. Xanthogranulomatous pyelonephritis in a renal allograft associated with xanthogranulomatous diverticulitis: report of the first case and review of the literature. Nephrol Dial Transplant 2007; 22:3344.

dexmedetomidine and cough

Q: Dexmedetomidine can be used as a cough suppressant during post-surgery extubation?

A) True

B) False

Answer: A 

A less known effect of Dexmedetomidine is its ability to suppress cough. Remifentanil, fentanyl and dexmedetomidine are effective cough suppressants. 

Although dexmedetomidine produces dose-dependent bradycardia and hypotension, a low dose bolus of 0.5 mcg/kg over 60 seconds, five minutes before the end of surgery, reduces cough on extubation in the recovery unit.

#procedures

References:

1. Tung A, Fergusson NA, Ng N, et al. Medications to reduce emergence coughing after general anaesthesia with tracheal intubation: a systematic review and network meta-analysis. Br J Anaesth 2020.

2. Guler G, Akin A, Tosun Z, et al. Single-dose dexmedetomidine attenuates airway and circulatory reflexes during extubation. Acta Anaesthesiol Scand 2005; 49:1088.

linezolid-induced lactic acidosis

Q; 73 years old nursing home resident with previous multiple ICU admissions is admitted again with MRSA-sepsis. Due to documented previous good responses, two weeks of Linezolid is prescribed. Patient is again showing good response with Linezolid. On 9th day of ICU admission, patient ABG is showing mild lactic acidosis (LA). Your next step? (select one)

A) Continue Linezolid as transient LA is common

B) Discontinue Linezolid immediately

Answer: B

Linezolid induced LA can be deadly with mortality up to 25 percent. Linezolid should be discontinued immediately at any sign of unexplained LA. It may take up to 2 weeks for LA to be resolved. The biggest risk factor is the prolonged or recurrent use of linezolid, but may occur as early as at first week. It is due to mitochondrial toxicity, given similarity between human mitochondrial 16S RNA and bacterial 23S rRNA.

#pharmacology

#ID

References:

1. Palenzuela L, Hahn NM, Nelson RP Jr, et al. Does linezolid cause lactic acidosis by inhibiting mitochondrial protein synthesis? Clin Infect Dis 2005; 40:e113.

2. Santini A, Ronchi D, Garbellini M, et al. Linezolid-induced lactic acidosis: the thin line between bacterial and mitochondrial ribosomes. Expert Opin Drug Saf 2017; 16:833.

3. Wiener M, Guo Y, Patel G, Fries BC. Lactic acidosis after treatment with linezolid. Infection 2007; 35:278.

4. Mao Y, Dai D, Jin H, Wang Y. The risk factors of linezolid-induced lactic acidosis: A case report and review. Medicine (Baltimore) 2018; 97:e12114.

Eosinophilias

Q: Hypereosinophilic syndromes (HES) is defined as absolute eosinophil count  AEC ≥1500/microL on two occasions (select one)

A) > 7 days apart

B) > 14 days apart

C) > 30 days apart

D) > 3 months apart

Answer: C

The objective of this question is to highlight the common misconceptions regarding the different definitions of eosinophilia. Conventionally, eosinophilia is defined as >5 percent of total WBC count. But merely looking at the percentage of the WBC may mislead a clinician. Eosinophilia is defined as AEC ≥500 eosinophils/microL. A clinician may have to calculate AEC by the following formula, as very high or low WBC count may change the value of AEC:

White blood cell (WBC) count/microL X percentage of eosinophils = AEC (eosinophils/microL) 

Also, there is a difference between eosinophilia, hypereosinophilia and hypereosinophilic syndromes (HES).

Eosinophilia is AEC ≥500 eosinophils/microL

Hypereosinophilia is ≥1500 eosinophils/microL 

Hypereosinophilic syndromes (HES) is AEC ≥1500/microL, on two occasions ≥30 days apart, plus at least one organ dysfunction attributable to eosinophilia. 

#hematology

#lab-medicine

References:

1. Tefferi A. Blood eosinophilia: a new paradigm in disease classification, diagnosis, and treatment. Mayo Clin Proc 2005; 80:75.

2.Roufosse F, Weller PF. Practical approach to the patient with hypereosinophilia. J Allergy Clin Immunol 2010; 126:39.

3. Klion A. Hypereosinophilic syndrome: current approach to diagnosis and treatment. Annu Rev Med 2009; 60:293.

trauma patient & intubation

Case: 24 years old male from a motor vehicle accident (MVA) is transported within 'golden hour' to a trauma center. On initial assessment, both lungs have good audible expansion on physical exam. CXR reported negative. Due to a decrease in Glasgow Coma Scale (GCS), the patient is intubated under video laryngoscopy with an Endotracheal tube (ETT), which was visibly seen to pass the vocal cord. The next best step is to? (select one)

A) auscultate the chest to rule out pneumothorax

B) CXR to confirm ETT placement above the carina

Answer: A

There are two objectives to cover in this case study.

1. Many patients with trauma may have small pneumothorax (aces). This may not be visible on initial CXR, but positive pressure ventilation may make it manifest. The first, easiest, and most helpful step is to re-auscultate the lungs, followed by CXR or ultrasound.

2. The concept of "golden hour" has traditionally been taught in trauma literature as the most important time period to decrease mortality, but the evidence in this regard is weaker than emphasized.

#trauma

References;

1. Newgard CD, Schmicker RH, Hedges JR, et al. Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a North American prospective cohort. Ann Emerg Med 2010; 55:235.

2. Newgard CD, Meier EN, Bulger EM, et al. Revisiting the "Golden Hour": An Evaluation of Out-of-Hospital Time in Shock and Traumatic Brain Injury. Ann Emerg Med 2015; 66:30.

Anti-hypertensive and transfusion related hypotension

 Q: Which of the following antihypertensive agents may have a direct synergistic effect during blood transfusion reactions? (select one)

A) ACE-Inhibitors (ACE-I)
B) B-blocker (BB)
C) Calcium channel blockers (CCB)
D) Diuretics 
E) Vasodilators


Answer: A

The synergistic effect of blood product transfusion and ACE-I causing hypotension is blamed on increased bradykinin levels in the transfused product. Some experts have suggested holding ACE-I for 24 hours before blood product transfusion, but evidence to use this practice is weak. It occurs mostly with platelet transfusion. It is also reported during apheresis procedures.

Primary hypotensive transfusion reaction is an exclusive transfusion reaction associated only with hypotension. It is not a part of other transfusion reactions like acute hemolytic reaction, transfusion-related acute lung injury (TRALI), and anaphylaxis.

#hemodynamic

References:

1. Metcalf RA, Bakhtary S, Goodnough LT, Andrews J. Clinical Pattern in Hypotensive Transfusion Reactions. Anesth Analg 2016; 123:268.

2. Owen HG, Brecher ME. Atypical reactions associated with use of angiotensin-converting enzyme inhibitors and apheresis. Transfusion 1994; 34:891.

3.  Hume HA, Popovsky MA, Benson K, et al. Hypotensive reactions: a previously uncharacterized complication of platelet transfusion? Transfusion 1996; 36:904.

Babinski sign

Q Negative Babinski sign (means no pathology) is demonstrated by? (select one)

A) extensor plantar response

B) flexor plantar response

Answer: B

Babinski sign is an easy-to-perform but important physical exam. If there is damage to the central nervous system (CNS) motor pathways, an abnormal reflex occurs (positive Babinski sign).

Babinski sign tends to elicit a plantar response by using a blunt, narrow surface (usually the back of the handle of a reflex hammer by stroking the sole of the patient's foot on the lateral edge, starting near the heel and proceeding along the lateral edge almost to the base of the little toe, then curve the path medially just proximal to the base of the other toes - J stroke). It requires a light touch but the clinician may decide to use some pressure if the test is equivocal or indeterminate the first time.

A normal patient will have all the toes flexed known as flexor plantar response. If there is damage to the CNS motor pathways, the great toe extends and the other toes fan out, called an extensor plantar response.

#physica-exam

#neurology

Reference:

Ambesh P, Paliwal VK, Shetty V, Kamholz S. The Babinski Sign: A comprehensive review. J Neurol Sci. 2017 Jan 15;372:477-481. doi: 10.1016/j.jns.2016.10.041. Epub 2016 Nov 2. PMID: 27823832.

Protamine risk

Q: Describe at least five sets of patient populations who are at high risk of protamine reaction?

Answer:

• Diabetics on NPH insulin,
• patients allergic to fish,
• pregnant and nursing women,
• previous protamine exposure, and
• men who have had vasectomies

#pharmacology

#hematology

References:

1. Brück S, Skrabal C, Träger K, Reinelt H. Kasuistik mit Literaturübersicht - Protamingabe bei Patientin mit Fischeiweißallergie [Risk factors for adverse reactions after protamine administration in adult patients undergoing cardiac surgery- a case report and literature review]. Anasthesiol Intensivmed Notfallmed Schmerzther. 2014 Jun;49(6):360-6. German. doi: 10.1055/s-0034-1383887. Epub 2014 Jul 8. PMID: 25004379.

2. Levy JH, Schwieger IM, Zaidan JR, Faraj BA, Weintraub WS. Evaluation of patients at risk for protamine reactions. J Thorac Cardiovasc Surg. 1989 Aug;98(2):200-4. PMID: 2755152.

Box jellyfish sting

Q: 26 years old ocean-surfer, while vacationing at an Australian beach, was brought to ED after an "Australian box jellyfish" sting and is now in severe cardiogenic shock. What's the next step? (select one) 

A) specific sheep serum antivenom 

B) removal of tentacles 

C) cold packs & irrigation with vinegar 

D) Rx for acute decompensated heart failure 

E) All of the above 

 

Answer: E 

 The objective of the above question is to emphasize the urgency of treatment in jellyfish stings, particularly C. fleckeri, popularly known as Australian box jellyfish, which shows the most venomous tendency and is known to cause potential cardiogenic shock or cardiac arrest. All treatments (conservative to antidote) should be applied simultaneously and early in the course or else patient can deteriorate quickly. Even though evidence to use specific sheep serum antivenom is very weak, there is nothing to lose in such a life-threatening situation. The antidote is most effective early in the course. The vial can be repeated three times if symptoms last. 

 #toxicity 

 References: 

 1. Isbister GK. Jellyfish stings. Aust Prescrib 2007; 30:117. 

 2. Australian Resuscitation Council. Guideline 9.4.5. Envenomation: Jellyfish stings. Available at: http://www.resus.org.au/guidelines/ (Accessed on June 27, 2023). 

 3. Currie BJ. Marine antivenoms. J Toxicol Clin Toxicol 2003; 41:301.

Ca and albumin

Q: Severe volume depletion tends to cause? (select one)

A) pseudohypercalcemia

B) pseudohypocalcemia 

Answer: A

This question aims to revisit the calcium-albumin relationship. It is well known that calcium level should be adjusted with albumin level as in hypoalbuminemia; total serum calcium concentration may be normal, though actual serum ionized calcium may be elevated.

In contrast, few clinicians pay attention to situations that may cause hyperalbuminemia, such as severe volume depletion and multiple myeloma. In such situations, the reverse happens with elevated serum total calcium concentration, where actual serum ionized calcium concentration stays normal. This is called pseudohypercalcemia. It has also been called factitious hypercalcemia, which is a misnomer.

#endocrinology

References:

1. Goltzman D. Approach to Hypercalcemia. [Updated 2023 Apr 17]. In: Feingold KR, Anawalt B, Blackman MR, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279129/

2. Ashrafi F, Iraj B, Nematollahi P, Darakhshandeh A. Pseudohypercalcemia in Multiple Myeloma: A Case Report. Int J Hematol Oncol Stem Cell Res. 2017 Jul 1;11(3):246-249. PMID: 28989592; PMCID: PMC5625476.

3. Walker MD, Shane E. Hypercalcemia: A Review. JAMA. 2022 Oct 25;328(16):1624-1636. doi: 10.1001/jama.2022.18331. PMID: 36282253.

Adrenal insufficiency and Ca

Q: Adrenal insufficiency may cause? (select one)

A) Hypercalcemia 

B) Hypocalcemia 

Answer: A

Adrenal insufficiency causes hypercalcemia, particularly in the Addisonian crisis. This occurs due to various simultaneous processes, including increased bone resorption, volume contraction, proximal tubular calcium reabsorption, hemoconcentration, and calcium binding to serum proteins. It takes several days for correction after cortisol gets administrated.

#endocrinology

References:

1. Muls E, Bouillon R, Boelaert J, et al. Etiology of hypercalcemia in a patient with Addison's disease. Calcif Tissue Int 1982; 34:523.

2. Montoli A, Colussi G, Minetti L. Hypercalcaemia in Addison's disease: calciotropic hormone profile and bone histology. J Intern Med 1992; 232:535.

shoulder abduction in cervical neuropathy

Q: 63 years old female with a BMI of 42 and a history of motor vehicle trauma, is now extubated after an episode of community-acquired pneumonia. Since extubation, she is complaining of right-sided neck and arm pain. Patient also required 'prone position' during her intubation. Cervical radiculopathy is suspected due to physical stress incurred while receiving pronation. Bedside clinical exam with Right shoulder abduction tends to make pain? (select one)

A) better

B) worse

Answer: A

There are three objectives of this question.

First, performing a prone position requires a trained team/staff. Patients can endure various physical trauma which can have long-lasting effects.

Second, a bedside clinical exam is essential as well as the most effective way of diagnosing various diseases.

Third, to provide simple conceptual knowledge that shoulder abduction at the same side where cervical radiculopathy is suspected, not only helps diagnose the pathology but also provides relief from the pain. Shoulder abduction test on the same side of cervical pain has a very high specificity for diagnosing cervical radiculopathy.

#physical-exam

#pulmonary

#musculo-skeletal

#neurology

References:

1. Rubinstein SM, Pool JJ, van Tulder MW, et al. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. Eur Spine J 2007; 16:307.

2. Offner PJ, Haenel JB, Moore EE, Biffl WL, Franciose RJ, Burch JM. Complications of prone ventilation in patients with multisystem trauma with fulminant acute respiratory distress syndrome. J Trauma. 2000 Feb;48(2):224-8. doi: 10.1097/00005373-200002000-00004. PMID: 10697078.

Cyclosporine and statins

Q: 54 years old male with chronic psoriasis, and on cyclosporine presented with acute myocardial infarction, managed with percutaneous coronary intervention (PCI). The patient is prescribed a statin. The dose of statin should be kept? (select one)

A) higher

B) lower

Answer: B

Cyclosporine increases serum concentrations of all statins. This interaction may cause adverse effects, particularly myositis. The most notorious statins in this regard are lovastatin and simvastatin. 

Pitavastatin, pravastatin, and rosuvastatin are less affected.

#pharmacology

#cardiology

Reference:

1. Wiggins BS, Saseen JJ, Page RL 2nd, et al. Recommendations for Management of Clinically Significant Drug-Drug Interactions With Statins and Select Agents Used in Patients With Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation 2016; 134:e468.

DM/PM associated ILD

Q: 54 years old female with an established diagnosis of dermatomyositis (DM) is admitted to ICU with community-acquired pneumonia which quickly developed into impending respiratory failure, and required intubation. There is a high concern for interstitial lung disease (ILD). Which of the following finding will favor the diagnosis of ILD? (select one)

A) eosinophilia

B) positive anti-Jo-1 antibody

C) restrictive pattern on PFT

D) a disproportionately low DLCO

Answer: B

Patients with known history of dermatomyositis (DM) or polymyositis (PM), have a very high risk of developing ILD. Said that it is not easy to make the diagnosis as these patients are usually on medications that can cause drug-induced pneumonitis, or respiratory muscle weakness causing dyspnea, or pulmonary hypertension. 

Although high resolution CT scan (HRCT) is essential to make the diagnosis but it should be read with other laboratory tests, as patient might have various other conditions combined.

• Peripheral blood eosinophilia favors drug-induced pneumonitis (choice A).
• Positive anti-Jo-1 is almost certain to establish the diagnosis of DM/PM-associated ILD (choice B).
• PFT with proportionately more restriction than gas transfer abnormality suggests respiratory muscle weakness (choice C).
• disproportionately low DLCO relative to lung volume suggests pulmonary hypertension (choice D).

#pulmonary

#rheumatology

References:

1. Marie I, Josse S, Hatron PY, Dominique S, Hachulla E, Janvresse A, Cherin P, Mouthon L, Vittecoq O, Menard JF, Jouen F. Interstitial lung disease in anti-Jo-1 patients with antisynthetase syndrome. Arthritis Care Res (Hoboken). 2013 May;65(5):800-8. doi: 10.1002/acr.21895. PMID: 23203765.

2. Leu CC, Lan JL. Anti-Jo-1 antibody in patients with polymyositis/dermatomyositis. Zhonghua Min Guo Wei Sheng Wu Ji Mian Yi Xue Za Zhi. 1992 Feb;25(1):41-7. PMID: 1306148.

3. Monti S, Montecucco C, Cavagna L. Clinical spectrum of anti-Jo-1-associated disease. Curr Opin Rheumatol. 2017 Nov;29(6):612-617. doi: 10.1097/BOR.0000000000000434. PMID: 28796005.

CLOT-AF score

Q: What is CLOT-AF score?

Answer: CLOTS‐AF score is a risk score to predict left atrial appendage thrombus (LAAT); however, LAAT risk factors remain poorly defined. It is a combination of clinical and noninvasive echocardiographic parameters.

On average, each 1‐point increment in the CLOTS‐AF risk score was associated with a nearly 2‐fold increased risk of LAAT.

#cardiology

Reference:

Louise Segan, et.al -   Identifying Patients at High Risk of Left Atrial Appendage Thrombus Before Cardioversion: The CLOTS‐AF Score,   Originally published, 10 Jun 2023 

https://doi.org/10.1161/JAHA.122.029259 - Journal of the American Heart Association. 2023;0:e029259

Acute HCV infection

Q: 26 years old surgical resident is admitted to ICU with Right Upper Quadrant (RUQ) pain, jaundice, white stool, and severe nausea and vomiting. Patient recently had a needle stick while performing the central line. Subsequent workup led to the diagnosis of acute Hepatitis C (HCV) infection. Appropriate approach is? (select one)

A) symptomatic treatment 

B) anti-viral therapy

Answer: B

American Association for the Study of Liver Diseases (AASLD) as well as the Infectious Diseases Society of America (IDSA) recommends immediate treatment upon documentation of viremia in people with acute HCV infection. Although, some clinicians may decide to wait for 3-6 months to determine whether chronic infection has been established, or infection is cleared. But, that should be done only if a patient refuses treatment or any other unavoidable circumstances. 

Anti-viral treatment prevents ongoing transmission and reduces incidence and prevalence in the population. Also, antiviral treatment prevents further severe acute HCV infection.

#ID

#hepatology

Reference:

HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C. Joint panel from the American Association of the Study of Liver Diseases and the Infectious Diseases Society of America. http://www.hcvguidelines.org/ (Accessed on July 01, 2023).

PCP in HIV patients

Q: Which of the following is the best predictor of Pneumocystis pneumonia (PCP) in HIV patients? (select one)

A) exercise-induced desaturation 

B) infiltrates on chest radiograph

C) resting arterial hypoxemia

Answer: A

Studies have shown that exercise-induced desaturation is a better indicator than an abnormal CXR in patients with Pneumocystis pneumonia (PCP) - OR 5.4 vs. 4.9. This becomes clinically more relevant when CXR is normal.

 

HIV patients without change in (A-a) oxygen gradient with exercise are very unlikely to have pulmonary disorder.

#pulmonary

#HIV

References:

1. Smith DE, Forbes A, Davies S, et al. Diagnosis of Pneumocystis carinii pneumonia in HIV antibody positive patients by simple outpatient assessments. Thorax 1992; 47:1005.

2. Stover DE, Greeno RA, Gagliardi AJ. The use of a simple exercise test for the diagnosis of Pneumocystis carinii pneumonia in patients with AIDS. Am Rev Respir Dis 1989; 139:1343.

Insulin, D-50 and K

Q: A bolus of 10 units of intravenous (IV) regular insulin and 50 mL of 50 percent dextrose(D-50) are expected to lower serum potassium level approximately by? (select one)

A) 1 mEq/L

B) 2 mEq/L

Answer: A

IV Insulin and D-50 are expected to reduce potassium by approximately 1 mEq/L. Insulin drives potassium inside the cells by enhancing Na-K-ATPase pump in skeletal muscles. 

The primary objective of this question is to address a common deficiency of inappropriate practice of glucose administration along with IV insulin. Although most clinicians administer D-50 with IV insulin to counter hypoglycemia, the hypoglycemia effect lasts way longer than IV insulin effect, particularly in patients with renal insufficiency. The serum glucose should be measured frequently, like every hour or earlier if clinical signs appear, at least for the next 6 hours. 

One unusual caveat that may harm the patient is that hypoglycemia may not manifest quickly but may develop an hour or after the infusions. It is prudent to run IV infusion of D-10 at 30-70 mL/hour for a few hours to avoid unintended consequences of hypoglycemia.

It takes about 10-15 minutes for insulin to take effect.

#endocrinology

#electrolytes

References:

1. Harel Z, Kamel KS. Optimal Dose and Method of Administration of Intravenous Insulin in the Management of Emergency Hyperkalemia: A Systematic Review. PLoS One 2016; 11:e0154963.

2. Sterns RH, Grieff M, Bernstein PL. Treatment of hyperkalemia: something old, something new. Kidney Int 2016; 89:546.

3. Tee SA, Devine K, Potts A, et al. Iatrogenic hypoglycaemia following glucose-insulin infusions for the treatment of hyperkalaemia. Clin Endocrinol (Oxf) 2021; 94:176.

hospitalization and smoking cessation

Q: Patients who undergo surgery during hospitalization are more likely to quit smoking than those who have not had surgery?

A) True

B) False

Answer: A

It is interesting to note that hospitalization positively influences patients to quit smoking. This may be due to a setting free of usual cues and access to tobacco. Illness also reinforces this, even if hospitalization is unrelated to smoking-induced disease. Patients who undergo surgery, particularly major surgery during hospitalization, are more likely to quit smoking than those who have not had surgery. 

Clinical significance: Patients should be encouraged to avoid tobacco after discharge during ICU or in-patient stay. Intensive counseling increases the likelihood of smoking cessation. Follow-up after discharge also increases the cessation rate.

#tobacco

References:

1. Shi Y, Warner DO. Surgery as a teachable moment for smoking cessation. Anesthesiology 2010; 112:102.

2. Rigotti NA, Clair C, Munafò MR, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev 2012; :CD001837.

3. Rigotti NA, Regan S, Levy DE, et al. Sustained care intervention and postdischarge smoking cessation among hospitalized adults: a randomized clinical trial. JAMA 2014; 312:719.