Q: Progesterone is also an “anticonvulsant.” True or false?
Answer: True
Catamenial epilepsy is defined as seizure exacerbation in women aligned with their menstrual cycle. It usually subsides in menopause and thought to be related to estrrogen. Progesterone is the mainstay of the treatment.
Wednesday, May 9, 2012
Tuesday, May 8, 2012
Q: What is Pagophagia?
Answer: Pagophagia is the compulsive consumption of ice or icey drinks. It has been very much associated and may be a presenting symptom of iron deficiency anemia. It gets resolved with iron supplementation.
There are 2 underlying resons for this pica. First, ice tastes better if the individual is iron deficient. Second, melting ice in mouth or chewing ice lessen pain in glossitis related to iron deficiency anemia.
Answer: Pagophagia is the compulsive consumption of ice or icey drinks. It has been very much associated and may be a presenting symptom of iron deficiency anemia. It gets resolved with iron supplementation.
There are 2 underlying resons for this pica. First, ice tastes better if the individual is iron deficient. Second, melting ice in mouth or chewing ice lessen pain in glossitis related to iron deficiency anemia.
Monday, May 7, 2012
Q: What is Beau's lines?
Answer: Beau's line appear as transverse lines across the nail as signs of previous acute illnesses like severe infection, mayocardial infarction, any kind of shock, hypocalcemia, any big surgery, immunosuppressive therapy or chemotherapy and severe zinc deficiency.
Mote interestingly, location on the nail may even provide the approximate date of the illness and the depth of the line provides a clue to the severity of the illness!
Answer: Beau's line appear as transverse lines across the nail as signs of previous acute illnesses like severe infection, mayocardial infarction, any kind of shock, hypocalcemia, any big surgery, immunosuppressive therapy or chemotherapy and severe zinc deficiency.
Mote interestingly, location on the nail may even provide the approximate date of the illness and the depth of the line provides a clue to the severity of the illness!
Sunday, May 6, 2012
Q: 23 year old female presented to ER with severe anaphylaxis reaction after eating shrimp. Airway seems compromised. As you prepare and proceed with intubation, you encounter severe vocal cord edema with no inlet visible. What should be your next step?
Answer: Administration of Epinephrine
The 2010 Joint Task Force anaphylaxis parameter update, the 2011 World Allergy Organization anaphylaxis guidelines. It recommends cardiopulmonary monitoring, administration of oxygen and placement of a a large-bore IV, resuscitation with isotonic crystalloid, placing the patient in a supine position with the legs elevated and Epinephrine injection.
Special and prompt attention should be paid to Airway. If severe vocal cord edema is encounter, repeat administration of epinephrine usually reverses the edema. Dose is 0.1-0.5 mg SC q10-15min. If edema persists, difficult airy protocol should be initiated.
Answer: Administration of Epinephrine
The 2010 Joint Task Force anaphylaxis parameter update, the 2011 World Allergy Organization anaphylaxis guidelines. It recommends cardiopulmonary monitoring, administration of oxygen and placement of a a large-bore IV, resuscitation with isotonic crystalloid, placing the patient in a supine position with the legs elevated and Epinephrine injection.
Special and prompt attention should be paid to Airway. If severe vocal cord edema is encounter, repeat administration of epinephrine usually reverses the edema. Dose is 0.1-0.5 mg SC q10-15min. If edema persists, difficult airy protocol should be initiated.
Saturday, May 5, 2012
Spontaneous Coronary Artery Dissection (SCAD)
SCAD is a rare condition characterised by an acute coronary syndrome in a patient whose age and sex suggest a low probability of atherosclerotic disease. Unfortunately, the natural history, particularly with proximal or extensive dissection, is unpredictable and warrants aggressive revascularisation.
Peripartum women are at increased risk due to changes in blood flow increasing shear stress, and progesterone driven vessel wall changes which may predispose to coronary dissection. Other risk factors involve Ehler-Dahnlos type IV, Marfan’s syndrome, strenuous exercise and drug induce like cocaine.
Treatment includes aspirin, B-blockers, +/- anticoagulants or glycoprotein IIb/IIIa inhibitors. Thrombolytic agents should be avoided as they may worsen the dissection process. Percutaneous intervention with deployment of a stent is the procedure of choice. The potential for stent deployment into the false lumen exists! Coronary artery bypass grafting remains the treatment of choice for very extensive, multi-vessel or the left main stem dissection.
SCAD is a rare condition characterised by an acute coronary syndrome in a patient whose age and sex suggest a low probability of atherosclerotic disease. Unfortunately, the natural history, particularly with proximal or extensive dissection, is unpredictable and warrants aggressive revascularisation.
Peripartum women are at increased risk due to changes in blood flow increasing shear stress, and progesterone driven vessel wall changes which may predispose to coronary dissection. Other risk factors involve Ehler-Dahnlos type IV, Marfan’s syndrome, strenuous exercise and drug induce like cocaine.
Treatment includes aspirin, B-blockers, +/- anticoagulants or glycoprotein IIb/IIIa inhibitors. Thrombolytic agents should be avoided as they may worsen the dissection process. Percutaneous intervention with deployment of a stent is the procedure of choice. The potential for stent deployment into the false lumen exists! Coronary artery bypass grafting remains the treatment of choice for very extensive, multi-vessel or the left main stem dissection.
Friday, May 4, 2012
Q: As you send pleural fluid to lab, initial report on computer reads - pH =7.18 and glucose = 58 mg/dL. Nothing else reported yet. Whats your concern?
Answer: Empyema
Usually empyema is tapped as frank pus or cloudy fluid from the pleural space. But it is very important to follow report on any thoracentesis as it is famously said that:
"The Sun Should Never Set on an Empyema".
Drainage should be planned ASAP. In empyema the pleural fluid typically has a leukocytosis, low pH (less than 7.20), low glucose (less than 60 mg/dL), a high LDH, elevated protein and may grow infectious organisms.
http://chestjournal.chestpubs.org/content/95/5/945.full.pdf
Answer: Empyema
Usually empyema is tapped as frank pus or cloudy fluid from the pleural space. But it is very important to follow report on any thoracentesis as it is famously said that:
"The Sun Should Never Set on an Empyema".
Drainage should be planned ASAP. In empyema the pleural fluid typically has a leukocytosis, low pH (less than 7.20), low glucose (less than 60 mg/dL), a high LDH, elevated protein and may grow infectious organisms.
http://chestjournal.chestpubs.org/content/95/5/945.full.pdf
Thursday, May 3, 2012
Q: What is folded lung syndrome?
Answer: It is the other name of rounded atelectasis. As an outer portion of the lung slowly collapses as a result of scarring and shrinkage of the pleura, it produces a rounded appearance on x-ray. It may give apperance of a mass or tumor. Rounded atelectasis is usually a complication of asbestos-induced disease of the pleura, but it may also result from other types of chronic scarring and thickening of the pleura.
Answer: It is the other name of rounded atelectasis. As an outer portion of the lung slowly collapses as a result of scarring and shrinkage of the pleura, it produces a rounded appearance on x-ray. It may give apperance of a mass or tumor. Rounded atelectasis is usually a complication of asbestos-induced disease of the pleura, but it may also result from other types of chronic scarring and thickening of the pleura.
Wednesday, May 2, 2012
Tuesday, May 1, 2012
Sunday, April 29, 2012
Saturday, April 28, 2012
Q: During apnea test for brain death evaluation, how much oxygen should be deliverd
Answer: 8 L/min
Before brain death evaluation, preoxygenate with 100% oxygen for 30 minutes and disconnect the ventilator. Place a cannula at the level of carina and delivers 8 L/mi
Click here to see a sample Apnea test protocol here
Thursday, April 26, 2012
Q: 60 year old male with ESRD (End Stage Renal Disease), and with history of A. Fib. is recently started on Pradaxa (Dabigatran). Patient presented with acute lower GI bleed. Patient took last dose about 12 hours ago. Knowing that reversal for Pradaxa is not available to you, what could be your option here?
Answer: Hemodialysis (HD)
Though Hemodialysis may not be fully effective but upto 60% of Dabigatran can be removed via hemodialysis and may provide some relief. Patient with already available access for HD should be given advantage of it with close volume monitoring and replacement.
For patients with creatinine clearance (CrCl) more than 30 mL/min, the recommended dose of PRADAXA is 150 mg twice daily. For patients with severe renal impairment (CrCl 15-30 mL/min), the recommended dose of PRADAXA is 75 mg twice daily.
Answer: Hemodialysis (HD)
Though Hemodialysis may not be fully effective but upto 60% of Dabigatran can be removed via hemodialysis and may provide some relief. Patient with already available access for HD should be given advantage of it with close volume monitoring and replacement.
For patients with creatinine clearance (CrCl) more than 30 mL/min, the recommended dose of PRADAXA is 150 mg twice daily. For patients with severe renal impairment (CrCl 15-30 mL/min), the recommended dose of PRADAXA is 75 mg twice daily.
Wednesday, April 25, 2012
Q: Ciprofloxacin is not a good choice in patients with myasthenia gravis. Why?
Answer: Ciprofloxacin is now known for more than 20 years to cause worsening of myasthenia gravis, including muscle weakness and breathing problems - and may require ventilatory support.
Other drugs which make MG worse include Beta-blockers, Lithium, Procainamide, Verapamil, Prednisone and Neuromuscular blocking agents.
Reference: http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/019537s075,020780s033lbl.pdf
Tuesday, April 24, 2012
Q: How Alcohol septal ablation is performed for hypertrophic cardiomyopathy (HCM)?
Answer: Alcohol septal ablation is not very different in technique from regular coronary angioplasty except here artifical occlusion is performed! After localizing the the septal artery feeding the hypertrophied muscle, a small amount of absolute alcohol is infused into the artery to produce infarction. Resulting chest pain can be treated with analgesics and sedatives. About 5-10% of patients may require permanent pacemaker.
This procedure should be performed by cardiologists with specific training in the procedure. This procedure is also called 'Sigwart procedure' as it was first performed by British cardiologist Ulrich Sigwart in 1994.
Answer: Alcohol septal ablation is not very different in technique from regular coronary angioplasty except here artifical occlusion is performed! After localizing the the septal artery feeding the hypertrophied muscle, a small amount of absolute alcohol is infused into the artery to produce infarction. Resulting chest pain can be treated with analgesics and sedatives. About 5-10% of patients may require permanent pacemaker.
This procedure should be performed by cardiologists with specific training in the procedure. This procedure is also called 'Sigwart procedure' as it was first performed by British cardiologist Ulrich Sigwart in 1994.
Monday, April 23, 2012
Q: Vancomycin can be given as?
A) Intravenous infusion
B) via oral route (PO)
C) Via inhaled Nebulizer
D) via topical application
E) via drops in eye/ears
F) All of the above
Answer: F
Vancomycin can be given via all the routes as described above. The objective of above question is to emphasis the inhaled administration of Vancomycin as other routes are fairly known to ICU physicians.
Lately, there has been various reports where inhaled Vancomycin has been used successfully to treat MRSA particularly in cystic Fibrosis patients.
A) Intravenous infusion
B) via oral route (PO)
C) Via inhaled Nebulizer
D) via topical application
E) via drops in eye/ears
F) All of the above
Answer: F
Vancomycin can be given via all the routes as described above. The objective of above question is to emphasis the inhaled administration of Vancomycin as other routes are fairly known to ICU physicians.
Lately, there has been various reports where inhaled Vancomycin has been used successfully to treat MRSA particularly in cystic Fibrosis patients.
Sunday, April 22, 2012
Q: Which one is more effective - IV Chloramphenicol or PO Chloramphenicol?
Answer: PO Chloramphenicol
Interestingly and unlike most other drugs PO Chloramphenicol is more effective than IV preparation of Chloramphenicol.
Pure chloramphenicol does not dissolve in water so it has to be prepare with succinate ester. Chloramphenicol succinate ester is an inactive prodrug and must first be hydrolysed to chloramphenicol; however, during hydrolysis 30% of the drug is lost.
To be effective, the dose needs to be increased to be equivalent to the oral dose!
Answer: PO Chloramphenicol
Interestingly and unlike most other drugs PO Chloramphenicol is more effective than IV preparation of Chloramphenicol.
Pure chloramphenicol does not dissolve in water so it has to be prepare with succinate ester. Chloramphenicol succinate ester is an inactive prodrug and must first be hydrolysed to chloramphenicol; however, during hydrolysis 30% of the drug is lost.
To be effective, the dose needs to be increased to be equivalent to the oral dose!
Saturday, April 21, 2012
Q: What is Peek sign?
Answer: Myasthenia gravis causes weakness, predominantly in bulbar, facial, and extra-ocular muscles.
The peek sign is manifestation of orbicularis fatigue. On lid closure to command, the orbicularis muscle initially may achieve lid apposition; however, as the patient continues to try to keep the eyes forcefully closed over a minute, the orbicularis oculi fatigues, and sometimes the lids separate to show a rim of sclera, with the patient appearing to "peek" at the examiner. With profound orbicularis fatigue, the cornea may become visible.
The peek sign can also be seen with VII nerve palsies.
Answer: Myasthenia gravis causes weakness, predominantly in bulbar, facial, and extra-ocular muscles.
The peek sign is manifestation of orbicularis fatigue. On lid closure to command, the orbicularis muscle initially may achieve lid apposition; however, as the patient continues to try to keep the eyes forcefully closed over a minute, the orbicularis oculi fatigues, and sometimes the lids separate to show a rim of sclera, with the patient appearing to "peek" at the examiner. With profound orbicularis fatigue, the cornea may become visible.
The peek sign can also be seen with VII nerve palsies.
Friday, April 20, 2012
Q: During traumatic spinal tap, protein may also get introduce into the CSF beside RBCs. What rule of thumb may help in differentiating between traumatic protein tap vs otherwise unsuspected neurologic disease?
Answer: An approximation of 1 mg of protein for every 750 RBCs may be used as a guide for probable traumatic tap. It is advisible to repeat spinal tap to confirm diagnosis.
A high CSF protein level, can be a clue to demyelinating polyneuropathies.
Answer: An approximation of 1 mg of protein for every 750 RBCs may be used as a guide for probable traumatic tap. It is advisible to repeat spinal tap to confirm diagnosis.
A high CSF protein level, can be a clue to demyelinating polyneuropathies.
Thursday, April 19, 2012
Q: What is Maddrey’s modified Discriminant Function (mDF) and its clinical implication?
Answer: American College of Gastroenterology defines severity of alcoholic hepatitis as a modified Discriminant Function(mDF). If score is more or equal to 32 and/or hepatic encephalopathy, it identifies the cutoff for severity. This is calculated as
mDF = 4.6 (PTpatient–PTcontrol)+ serum bilirubin (µmol/l)/17.
mDF more/= 32 and/or hepatic encephalopathy was associated with a 65% 28-day survival in placebo treated patients. While those with a score less than 32 had a survival of 93%.
American College of Gastroenterology recommends prednisolone should be used in patients with severe alcoholic hepatitis ( where mDF more/= 32) in whom the diagnosis is certain.
Tuesday, April 17, 2012
Caspofungin data in recipients of liver transplant
One recent study did retrospective analysis of death, adverse events (AE), fungal infections, and hepatic function among recipients of liver transplantation (105 patients) at high risk of fungal infection who received prophylactic treatment with caspofungin.
Post-transplant patients at high risk for fungal infection are commonly defined by the presence of at least one of the following: (i) re-transplantation; (ii) re-operation; (iii) renal dysfunction. However, in our practice, patients are also considered at high risk for developing fungal infections if they present with the following: (iv) fever of unknown origin; (v) hypothermia; (vi) positive random culture for fungus at the time of transplant (bile and/or ascites); (vii) sepsis; (viii) use of vasopressors; (ix) re-intubation, during the first hospitalization after liver transplant; (x) prolonged intubation ( more than 24 h), and (xi) acute respiratory distress syndrome, until negative fungal cultures are obtained.
Exact conditional logistic regression was used to compare the risk of death, AEs, and fungal infections between patients who received caspofungin, other antifungal drugs, and no antifungal drugs.
Analyses were then performed with SAS 9.1 (SAS Institute Inc., Cary, NC, USA). Patients were between 27 and 72 yr old (mean = 55), with two-thirds male and three-quarters Caucasian. Sixteen patients received caspofungin (11 preventively), and 32 received other antifungal (26 preventively).
There were no proven fungal infections among the patients who received caspofungin, three infections among patients who received other antifungal (3/26 = 12%), and 14 infections among patients who were not preventively treated (14/45 = 31%). These infection rates were significantly different across the three groups (p = 0.029), with caspofungin and other antifungal preventive treatment comparable (p = 0.540), and both better than no preventive treatment at all (OR = 0.15, p = 0.049, for caspofungin versus no preventive treatment; OR = 0.29, p = 0.085, for other antifungal versus no preventive treatment).
Caspofungin appears to be an effective preventive agent against fungal infections when used in recipients of liver transplant designated as high risk for fungal infection. Usage of caspofungin in these patients does not carry an apparent increase in risk of death or acute cellular rejection, although we observed a significantly higher risk of AEs, especially acute renal failure (p = 0.001), in patients who received this agent.
Reference: Clin Transplant. 2011 Jul-Aug;25(4):569-75.
Post-transplant patients at high risk for fungal infection are commonly defined by the presence of at least one of the following: (i) re-transplantation; (ii) re-operation; (iii) renal dysfunction. However, in our practice, patients are also considered at high risk for developing fungal infections if they present with the following: (iv) fever of unknown origin; (v) hypothermia; (vi) positive random culture for fungus at the time of transplant (bile and/or ascites); (vii) sepsis; (viii) use of vasopressors; (ix) re-intubation, during the first hospitalization after liver transplant; (x) prolonged intubation ( more than 24 h), and (xi) acute respiratory distress syndrome, until negative fungal cultures are obtained.
Exact conditional logistic regression was used to compare the risk of death, AEs, and fungal infections between patients who received caspofungin, other antifungal drugs, and no antifungal drugs.
Analyses were then performed with SAS 9.1 (SAS Institute Inc., Cary, NC, USA). Patients were between 27 and 72 yr old (mean = 55), with two-thirds male and three-quarters Caucasian. Sixteen patients received caspofungin (11 preventively), and 32 received other antifungal (26 preventively).
There were no proven fungal infections among the patients who received caspofungin, three infections among patients who received other antifungal (3/26 = 12%), and 14 infections among patients who were not preventively treated (14/45 = 31%). These infection rates were significantly different across the three groups (p = 0.029), with caspofungin and other antifungal preventive treatment comparable (p = 0.540), and both better than no preventive treatment at all (OR = 0.15, p = 0.049, for caspofungin versus no preventive treatment; OR = 0.29, p = 0.085, for other antifungal versus no preventive treatment).
Caspofungin appears to be an effective preventive agent against fungal infections when used in recipients of liver transplant designated as high risk for fungal infection. Usage of caspofungin in these patients does not carry an apparent increase in risk of death or acute cellular rejection, although we observed a significantly higher risk of AEs, especially acute renal failure (p = 0.001), in patients who received this agent.
Reference: Clin Transplant. 2011 Jul-Aug;25(4):569-75.
Monday, April 16, 2012
Q: 48 year old female who is on "Cipro" for last 5 days due to severe urinary tract infection (UTI), is now complaining of diplopia. What is your concern?
Answer; Damage may be permanent
Ciprofloxacin has been repoted to cause diplopia which may be permanent. It may also cause complete loss of vision and impaired color vision but those are usually reversible.
Answer; Damage may be permanent
Ciprofloxacin has been repoted to cause diplopia which may be permanent. It may also cause complete loss of vision and impaired color vision but those are usually reversible.
Sunday, April 15, 2012
5th generation cephelsporin!
Ceftobiprole is a fifth-generation cephalosporin antibiotic with activity against MRSA, Pseudomonas aeruginosa, and enterococci. It is on Fast track for FDA approval. Ceftobiprole has already been approved for use in Canada and Switzerland.
Ceftobiprole is the first, broad-spectrum, anti-MRSA cephalosporin. It is also the first of antimicrobials to include anti-MRSA and anti-Pseudomonas activity in the spectrum of its coverage - providing single coverage for both. The dosing ris 500 mg IV every 8 hours or every 12 hours. Dosing adjustments may be necessary in patients with renal insufficiency.
Ceftobiprole is a fifth-generation cephalosporin antibiotic with activity against MRSA, Pseudomonas aeruginosa, and enterococci. It is on Fast track for FDA approval. Ceftobiprole has already been approved for use in Canada and Switzerland.
Ceftobiprole is the first, broad-spectrum, anti-MRSA cephalosporin. It is also the first of antimicrobials to include anti-MRSA and anti-Pseudomonas activity in the spectrum of its coverage - providing single coverage for both. The dosing ris 500 mg IV every 8 hours or every 12 hours. Dosing adjustments may be necessary in patients with renal insufficiency.
Saturday, April 14, 2012
Q: 28 year old female with previous history of postpartum cardiomyopathy is again admitted to ICU with 28 weeks pregnancy and shortness of breath. Cardiology service wrote for Cardiac MRI. Nusre needs your input on safety in view of pregnancy?
Answer: Cardiac MRI is safe to perform after first trimester of pregnancy. So far, there is no evidence found that MRI is dangerous to a fetus. Only precaution required is to avoid MRI contrast in pregnant patients.
Also, Cardiac MRI is safe with coronary stents, joint replacements, sternal wires, and prosthetic heart vales.
Answer: Cardiac MRI is safe to perform after first trimester of pregnancy. So far, there is no evidence found that MRI is dangerous to a fetus. Only precaution required is to avoid MRI contrast in pregnant patients.
Also, Cardiac MRI is safe with coronary stents, joint replacements, sternal wires, and prosthetic heart vales.
Friday, April 13, 2012
2 less appreciated factor in Variceal bleed beside obstruction
Obstruction of portal venous flow, whatever the etiology, results in a rise in portal venous pressure. This is a well know documented etiology. But there are 2 other factors which may play part in increase portal pressure and variceal bleed.
1. Increase Endothelin-1 (ET-1) which is a powerful vasoconstrictor synthesized by sinusoidal endothelial cells and causes increased hepatic vascular resistance of cirrhosis and the development of liver fibrosis.
2. Nitric Oxide (NO) is a known vasodilator substance that is synthesized by sinusoidal endothelial cells. In the cirrhotic liver, the production of NO is decreased.
Gupta TK, Toruner M, Chung MK, Groszmann RJ. Endothelial dysfunction and decreased production of nitric oxide in the intrahepatic microcirculation of cirrhotic rats. Hepatology. Oct 1998;28(4):926-31.
Obstruction of portal venous flow, whatever the etiology, results in a rise in portal venous pressure. This is a well know documented etiology. But there are 2 other factors which may play part in increase portal pressure and variceal bleed.
1. Increase Endothelin-1 (ET-1) which is a powerful vasoconstrictor synthesized by sinusoidal endothelial cells and causes increased hepatic vascular resistance of cirrhosis and the development of liver fibrosis.
2. Nitric Oxide (NO) is a known vasodilator substance that is synthesized by sinusoidal endothelial cells. In the cirrhotic liver, the production of NO is decreased.
Gupta TK, Toruner M, Chung MK, Groszmann RJ. Endothelial dysfunction and decreased production of nitric oxide in the intrahepatic microcirculation of cirrhotic rats. Hepatology. Oct 1998;28(4):926-31.
Thursday, April 12, 2012
Endotracheal Tube Cuff Pressure
Endotracheal tube cuff pressure must be kept within an optimal range that ensures ventilation and prevents aspiration while maintaining tracheal perfusion.
One study published in AJCC about a year ago looked into 32 orally intubated patients receiving mechanical ventilation for two 12-hour shifts labelled as randomized control and intervention condition respectively.
Continuous cuff pressure monitoring was initiated, and the pressure was adjusted to a minimum of 22 cm H2O. Caregivers were blinded to cuff pressure data.
Endotracheal tube cuff pressure must be kept within an optimal range that ensures ventilation and prevents aspiration while maintaining tracheal perfusion.
One study published in AJCC about a year ago looked into 32 orally intubated patients receiving mechanical ventilation for two 12-hour shifts labelled as randomized control and intervention condition respectively.
Continuous cuff pressure monitoring was initiated, and the pressure was adjusted to a minimum of 22 cm H2O. Caregivers were blinded to cuff pressure data.
- Usual care was provided during the control condition.
- During the intervention condition, cuff pressure alarm or clinical triggers guided the intervention.
It was found that
-
During the control condition, 51.7% of cuff pressure values were out of range compared with 11.1% during the intervention condition (P less than .001).
-
During the intervention, a mean of 8 adjustments were required, mostly to add air to the endotracheal tube cuff.
-
During the control condition, cuff pressure decreased over time (P less than .001).
Evaluation of an
Intervention to Maintain Endotracheal Tube Cuff Pressure Within Therapeutic
Range - Am J Crit Care
March 2011 , vol. 20 no. 2
109-118
Wednesday, April 11, 2012
Q: What is the 20-30-40 rule in myasthenic crisis?
Answer: The 20-30-40 rule is the most helpful and reliable indicator to decide when intubation is necessary in Myasthenia Crisis.
Answer: The 20-30-40 rule is the most helpful and reliable indicator to decide when intubation is necessary in Myasthenia Crisis.
- vital capacity less than 20ml/kg;
- peak inspiratory pressure less than −30 cm H2O
- peak expiratory pressure less than 40 cm H20
Tuesday, April 10, 2012
Monday, April 9, 2012
Q: What precaution should be taken while giving Pralidoxime as antidote for organophosphate poisoning?
Answer: It should be given slowly over 30 minutes. If given as bolus it may precipitate respiratory or cardiac arrest. Dose is 30 mg/kg.
If intravenous access is not available, it may be given as intramuscular or subcutaneous injection.
Answer: It should be given slowly over 30 minutes. If given as bolus it may precipitate respiratory or cardiac arrest. Dose is 30 mg/kg.
If intravenous access is not available, it may be given as intramuscular or subcutaneous injection.
Sunday, April 8, 2012
Q: 17 year old male presented to ER after he accidentally ingested only 1 teaspoon of oil of wintergreen at his farmhouse. Initially he decided to stay away due to minor ingestion but brought to ER by parents 'just for checkup'. What is your concern?
Answer: Salicylate Toxicity
One teaspoon of oil of wintergreen (98% methyl salicylate) contains 7000 mg of salicylate (nearly 90 baby aspirins). It should be considered as true toxicology emergency.
Answer: Salicylate Toxicity
One teaspoon of oil of wintergreen (98% methyl salicylate) contains 7000 mg of salicylate (nearly 90 baby aspirins). It should be considered as true toxicology emergency.
Saturday, April 7, 2012
Q: Give 7 risk factors for development of Zygomycosis 1?
Answer: Zygomycosis or Mucormycosis 1 is a fungal infection which is found mostly in diabetic patients. It is found to be associated with some interesting risks factors
1. Acidosis
2. Renal insufficiency
3. Diarrhea
4. Aspirin intake
Answer: Zygomycosis or Mucormycosis 1 is a fungal infection which is found mostly in diabetic patients. It is found to be associated with some interesting risks factors
1. Acidosis
2. Renal insufficiency
3. Diarrhea
4. Aspirin intake
5. Glucocorticoids intake
6. Deferoxamine intake
7. Splenectomy
1. Zygomycosis is the broadest term to refer to infections caused by bread mold fungi and includes mucormycosis, phycomycosis and basidiobolomycosis. "Mucormycosis" and "zygomycosis" are used interchangeably.
Friday, April 6, 2012
Daptomycin and Eosinophilic pneumonia
Daptomycin may cause eosinophilic pneumonia,
somewhere between 2 to 4 weeks after initiation of daptomycin therapy. in 2010
seven confirmed cases were reported and 36 were suspicious of it. Symptoms
resolved when daptomycin was discontinued but recurred in two patients when the
drug was restarted.
Eosinophilic pneumonia should be suspected in
patients receiving daptomycin who develop new or worsening fever, cough or
dyspnea. Peripheral eosinophilia may or may not be present, but BAL eosinophil
counts are usually elevated. The primary treatment is discontinuation of
daptomycin, along with respiratory support and, +/- , steroids.
Thursday, April 5, 2012
Q: Zosyn (Piperacillin/tazobactam) need
to be adjusted in renal failure patients on hemodialysis. Does it need to be
adjusted in patients on CVVHD?
Answer: NO
Dose Zosyn (Piperacillin/tazobactam) does not need to be adjusted in renal failure patients on CVVHD. It would be as like a patient with normal kidney function.
In patients on HD dose is usually: 2.25 g IV Q8h
In patients on CVVHD, dose is usually: 3.375 g IV Q6h or 4.5g IV Q8h
Answer: NO
Dose Zosyn (Piperacillin/tazobactam) does not need to be adjusted in renal failure patients on CVVHD. It would be as like a patient with normal kidney function.
In patients on HD dose is usually: 2.25 g IV Q8h
In patients on CVVHD, dose is usually: 3.375 g IV Q6h or 4.5g IV Q8h
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