Q: What is "Whoosh test"? 


Answer: The whoosh test is done by rapidly injecting air down the NasoGastric tube while auscultating over the epigastrium. Gurgling indicates probability of NGT in the stomach, whilst its absence suggests NGT is elsewhere (lung, oesophagus, pharynx etc).

Tandem Heart

Q: Ischemic colitis remained a clinical diagnosis. Despite normal labs or no bloody stools, which one clinical sign should promptly lead to diagnosis of Ischemic colitis?

Answer: "pain out of proportion to physical findings", specifically excruciating abdominal pain despite limited focal tenderness. Labs and other clinical signs may lag behind.

Q: ID service advise you to consider Octreotide for a patient with Aids related diarrhea. What is the dosing?


Answer: 100 to 500 mcg SC tid


Though evidence is weak but Octrotide has been used in AIDS related refractory chronic diarrhea. Octreotide is a candidate drug for the treatment of these patients as it inhibits gastrointestinal motility and increase the transit time.

Q: 58 year old male with Renal failure, but not yet on dialysis, is admitted with ST elevation MI and taken to cath lab for PCI and stent placement. Patient is back in unit and has been written to be started on glycoprotein IIb/IIIa inhibitor. What would be your choice?


Answer: Reopro Eptifibatide gets renal elimination and in such patients Abciximab (Reopro) would be a better choice.

In case Integrilin has to be given, renal dosing should be provided.

Update on platelet inhibition assay (for Plavix monitoring) 

 The VerifyNow P2Y12 assay is used for monitoring platelet inhibition for patients on medications like clopidogrel (plavix). The company has modified the assay so that, from now on, the instrument will only report out in “P2Y12 Reaction Units” or PRU, % inhibition will no longer be reported. 

The normal reference range is 194-418 PRU. Based on a review of the literature, the optimal P2Y12 result for patients on clopidrogrel is approximately 240 – 180 PRU. 

•  above 240 PRU the patient is at increased risk of thrombosis, 
•  below 180 PRU the patient is at increased risk of bleeding.

Q: While working in ICU you over heard on hospital paging system "Code Silver". What does it mean?

Answer: A person with weapon in hospital!

Hospitals may use their own codes but few codes are universally and informally shared by all.

Animation of TIPS

Q: Why steroids remain mainstay of treatment in Neurocysticercosis?


Answer: Albendazole and Praziquantel are both effective in treatment of Neurocysticercosis. They are given under cover of steroids. Steroids are essentially needed as inflammatory reactions to the dying parasite could be life threatening with mental status changes and convulsions.

Also, Albendazole when co administered with a steroid (to treat inflammation) results in increased absorption of albendazole.

Both Albendazole and Praziquantel are recommended to give with fatty meal.

Earplugs in ICU

"The use of earplugs during the night lowered the incidence of confusion in the studied intensive care patients. A vast improvement was shown by a Hazard Ratio of 0.47 (95% confidence interval (CI) 0.27 to 0.82). Also, patients sleeping with earplugs developed confusion later than the patients sleeping without earplugs. After the first night in the ICU, patients sleeping with earplugs reported a better sleep perception."

Read interesting article recently published at ccforum.com

The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients: Critical Care 2012, 16:R73

URL: http://ccforum.com/content/16/3/R73

Q: Inverted sleep-wake pattern (i.e sleeping by day and being awake at night), is the hallmark or at least sign of which encephelopathy?



Answer: Hepatic Encephelopathy

Mild to moderate hepatic encephalopathy is characterized by forgetfulness, confusion, irritability, inverted sleep-wake pattern, irritability, tremors etc.

Q: 52 year old male patient has been overdosed in ICU with Ambien (Zolpidem) due to medication error. What intervention may help to diagnose as well as reverse the effect of Ambien?


Answer: Flumazenil

Zolpidem's (ambien) hypnotic effects are similar to those of the benzodiazepine, though molecularly it is distinct from the classical benzodiazepine. But due to similarlity in their hypnotic effects, Flumazenil which is a benzodiazepine receptor antagonist, also reverses zolpidem's sedative/hypnotic effect.

Q: Which drug overdose may present as ST elevation MI?




Answer: Eszopiclone (lunesta)

Lunesta is unique in a sense that its overdose may presents as ST elevation MI with increase Troponin due to coronary vasospasm. It may lead to V. Fib. as well as cardiac arrest.



Lunesta overdose: ST-elevation coronary vasospasm, troponemia, and ventricular fibrillation arrest.- Am J Emerg Med. 2006 Oct;24(6):741-6.

Q: Which ACE Inhibitor is well known to cause taste disturbances?


Answer: Captopril

Taste disturbance, infrequent with most ACE inhibitors, is more prevalent in captopril and is attributed to its sulfhydryl moiety. Though captopril is not in much use in USA, it is still very much in use in developing countries due to its cost effectiveness.

Q: In Ascites, if patient requires both spironolactone and furosemide - what combination minimize the danger of hypokalemia?


Answer: Generally, patients with ascites respond well to spironolactone. For nonresponders, a loop diuretic may also be added.

The ratio of 100 mg : 40 mg reduces risks of hypokalemia.

Q: 23 year old male is admitted to ICU after severe Abdominal pain. CT scan reports foreign body obstruction. GI service performed upper and lower GI scope and advised surgical consult. Their diagnosis was Rapunzel syndrome?


Answer: The Rapunzel syndrome is a rare intestinal condition resulting from condition called trichophagia (eating hair).

Trichophagia is a severe form of condition called Trichotillomania (also known as "trichotillosis"). It is the compulsive urge to pull out one's own hair leading to noticeable hair loss. In trichophagia, people with trichotillomania may also ingest the hair that they pull; which can lead to a hair ball formation in GI tract called trichobezoar, and may cause GI obstruction.

Rapunzel syndrome, is an extreme form of trichobezoar in which the "tail" of the hair ball extends into the intestines, can be fatal if misdiagnosed. Because the human gastrointestinal tract is unable to digest human hair, the trichobezoar may require surgical treatment.

The syndrome is named after the long-haired girl Rapunzel in the fairy tale.

Neurology


Q: What is Ribot's law of retrograde amnesia?



Answer: Ribot's Law of retrograde amnesia states that there is a time gradient in retrograde amnesia, so that recent memories are more likely to be lost than the more remote memories.

Some examples are, in which bilingual patients recovered different languages with differential progress. In some cases, aphasics recover or preferentially improve only the first-acquired language.

Please note, in Neurology, Ribot’s Law is not universally accepted.

Q: What are the 3 major causes of false or factitious or pseudo hyponatremia?


Answer:

1. Severe hypertriglyceridemia,
2. Massive elevation of immunoglobulins as in multiple myeloma,
3. Severe hyperglycemia.

Q: Is Verapmil an anti- malarial drug?

Answer: Sort of !!

Verapamil has shown potential use in the treatment of malaria as an adjuvant treament with chloroquine particularly in resistance. Resistance to chloroquine is caused by the parasite cell's ability to expel the drug outside of its digestive vacuole. Verapamil, when used in combination with chloroquine, enhances the accumulation of chloroquine within a parasitic cell's digestive vacuole, rendering it incapable of detoxifying itself and making it more susceptible to death.

Recent resistance to the anti-malarial drug chloroquine has hindered the treatment of malaria in Southeast Asia, South America and Africa. Adjuvant use of verapamil may be useful in such circumstances.


Martin, S.; Oduola, A.; Milhous, W. (1987). "Reversal of chloroquine resistance in Plasmodium falciparum by verapamil". Science 235 (4791): 899–901

Q: 74 year old with previous history of CHF developed atrial fibrillation with RVR (rapid ventricular rate) pre-operatively which was controlled with IV cardizem drip. Cardizem was continued. Patient developed signs and symptoms of Malignant Hyperthermia during surgery. IV dantrolene was administerated. Patient became hypotensive, developed V.Tach., collapsed and died?



Answer: Calcium channel blockers such as diltiazem (Cardizem) or verapamil may cause severe hemodynamic problems if concomittently administerated with Dantrolene. It may lead to severe cardiovascular collapse, arrhythmias, myocardial depressions, and hyperkalemia.

Q: What is Prothrombin complex concentrates (PCC)?


Answer: Prothrombin complex concentrates (PCC) are derived from human plasma and contain the vitamin K dependent coagulation factors II, VII, IX, and X at varying concentrations. Several international guidelines as well as American College of Chest Physicians, now recommends PCC for warfarin reversal in patients with serious bleeding. The use of PCC in the United States (US) is still not widespread.


Prothrombin Complex Concentrate Versus Standard Therapies for INR Reversal in Trauma Patients Receiving Warfarin - Ann Pharmacother July/August 2011 vol. 45 no. 7/8 869-875

Q: Thyrotoxic patients with atrial fibrillation

A) require a lower maintenance dose of warfarin than euthyroid patients

or

B) require a higher maintenance dose of warfarin than euthyroid patients

(Select one)

Answer: A Thyrotoxic patients may require a lower maintenance dose of warfarin than euthyroid patients in atrial fibrillation because of increased clearance of vitamin K–dependent clotting factors.



Fadel BM, Ellahham S, Ringel MD, et al. Hyperthyroid heart disease. Clin Cardiol 2000;23: 402–8.

Q: Cipro associated seizure can occur with

A) thyrotoxicosis
B) high doses of the drug, old age,
C) renal insufficiency,
D) drug interactions
E) electrolyte abnormalities,
F) history of seizure
G) Allof the above



Answer: All of the above

Objective of this question is to enhance the relatively less known risk factor of seizure associated with ciropfloxacin intake i.e, thyrotoxicosis. Unrelated to it, cipro itself can cause unexplained hypothyroidism.

Q: 44 year old male with history of seizure is admitted with breakthrough seizure and has been loaded with phenytoin. His regular dose has been increased. Since morning patient is complaining of vision problem. On examination he has opthalmoplegia. What is your concern?


Answer: Phenytoin overdose

One of the side effect of Phenytoin intoxication is ophthalmoparesis, also know as opthalmoplegia. This opthalmoplegia may take weeks to resolve.

Q: What is the pitfall of PO amiodarone (oral)?


Answer: When given orally, the bioavailability of amiodarone is very variable. Absorption ranges from 22 to 95%.

Amiodarone may better absorp when it is given with food.

Amiodarone induced optic neuritis!

Amiodarone is one of the most commonly used medicine in ICU. In past, we have done many pearls related to IV amiodarone.One of the other unusual and common presentation of Amiodarone toxicity is optic neuritis. Optic neuritis may occur at any time following initiation of therapy. If any symptoms of visual impairment appear, like change in visual acuity or decrease in peripheral vision, prompt ophthalmic consult is recommended.

Picture diagnosis

Q: 76 year old male is seen in ER with this x-ray after fall to rule out cranial fracture. Is this an artifact or real? 

Answer: It is deep brain stimulator surgically inplanted

Q: 76 year old male is admitted in ICU for Bradycardia secondary to beta-blocker prescribed for his essential tremor. You received nursing call at night that patient is now requesting alcohol to abort his symptoms of essential tremor as it is always helpful to him?


Answer: It is true that Alcohol decrease the synptoms of essential tremor. The mechanism of tremor reduction by alcohol is unknown.

The recommeded treatment is propranolol. And if propranolol is contraindicated, primidone is an alternative choice. Other drugs which have shown effects include Gabapentin, Clonazepam or Topiramate.

Surgical treatment is reserved for the severe cases include thalamotomy and deep brain stimulation.

Q: What is Dopamine dysregulation syndrome? 

 Answer: It is an interesting syndrome, may seen on people on long term Dopamine replacement therapy (DRT) like Levadopa in Parkinson's Disease. It is characterized by addiction to DRT medication (taking extra doses), gambling, hypersexuality, shopping, eating disorder, euphoria, psychosis etc. marked by periods in between of dysphoria, sadness, psychomotor slowing, fatigue, apathy etc., reulting from DRT withdrawal. One interesting symptom during euphoria phase is punding, repetition of complex motor behaviors such as collecting or arranging objects. 

Management is drug dose stratification.

Q: 22 year old male in ICU is admitted for unrelated reason, continue to show prolonged PTT but normal PT, Bleeding Time and Platelet count. Which disease process only prolonges PTT but all other normal basic coagulation profile?


Answer: Factor X11 deficiency

Factor X11 deficiency is also known as Hageman factor deficiency. It is very rare with evidence of about 1 in 1 million. Fortunately its a benign process, does not cause bleeding and normally do not need treatment. Even with major surgery, bleeding manifestations are extremely rare. Usually, it is diagnosed accidently by a prolonged activated partial thromboplastin time (aPTT) test.

PICC line insertion

PICC line under ultrasound

(2 parts)

Truvada

Truvada (Tenofovir/emtricitabine), is a fixed-dose combination of two antiretroviral drugs, consisting of 300 milligrams of tenofovir and 200 milligrams of emtricitabine. The drug has been just approved for use as a pre-exposure prophylaxis against HIV infection. It significantly decreased the risk of contracting HIV. It is approved for non-infected men who have sex with multiple male partners.

Side effects include nausea, vomiting, dizziness and renal toxicity. Also, Lactic acidosis, steatosis and post treatment exacerbation of Hepatitis B.