BMV

Q: During bag-mask ventilation (BMV), what is the best way to reduce the likelihood of decreasing gastric inflation? 


 Answer: Squeezing the bag slowly over one full second reduces the likelihood of decreasing gastric inflation. A slowly delivered tidal volume prevents sufficient pressure to open the gastroesophageal sphincter.

It also helps to prevent a dramatic impact on the cardiac output of a patient.

#procedure


Reference: 

Fitz-Clarke JR. Fast or Slow Rescue Ventilations: A Predictive Model of Gastric Inflation. Fitz-Clarke JR1. Respir Care. 2018 May;63(5):502-509. doi: 10.4187/respcare.05620.

LRINEC

Q: Which of the following is not part of Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score?

A) C-reactive protein 
B) White blood cell  
C) Hemoglobin  
D) Potassium 
E) Creatinine


Answer: D

NF at the base is a clinical diagnosis. If suspicion for necrotizing fasciitis is high on clinical grounds, the patient should proceed straight to the OR. LRINEC should be calculated in equivocal cases. All of the above are the part of score except potassium. Instead, sodium is included in the score. 135 meq/L is the cutoff point for sodium in LRINEC score. 

LRINEC calculators are available at various web search engines (Ref#2) and very easy to calculate with only five components. A score of 8 has a PPV of 93.4% for NF.

#musculo-skeletal 


References:

1. Wong CH, Khin LW, Heng KS, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 2004; 32:1535.


2. https://www.mdcalc.com/lrinec-score-necrotizing-soft-tissue-infection#next-steps

ICA and VA dissections

Q: Transient monocular blindness is more common with? (select one) 

A) Internal carotid artery dissection 
B) Vertebral artery dissection 


 Answer: A

 Transient monocular blindness exclusively occurs in internal carotid artery dissection (ICA-D).

Although cerebral and cervical arterial dissections can occur at any age, they are a common cause of stroke in the young, and the most highly associated factor is the strenuous physical activity. Clinically, spontaneous cerebral and cervical artery dissection can be differentiated before imagings can be pursued. Internal carotid artery dissection (ICA-D) is relatively more common in men. The history of infection in the previous week is more common with ICA-D, and the history of cervical trauma in the previous week is more common with vertebral artery dissection (VA-D). Similarly, neck pain is more associated with VA-D. 


#neurology


Reference:

Debette S, Grond-Ginsbach C, Bodenant M, et al. Differential features of carotid and vertebral artery dissections: the CADISP study. Neurology 2011; 77:1174.

Toxicology

Q: 52 year old mining worker is admitted to ICU with episodes of torsades de pointes after an exposure to large amount of fumes. Patient c/o abdominal cramps, watery diarrhea and a garlic odor of the breath and stool. Toxicity of which element should be suspected? 


Answer: Arsenic

Acute arsenic poisoning has some distinct characteristics like abdominal symptoms but with severe watery diarrhea, a garlic odor of the breath and stool, QTc prolongation with or without torsades de pointes, acute respiratory distress syndrome, acute encephalopathy with or without seizures, proteinuria, hematuria, and acute tubular necrosis. This list continues and involves almost every body system.

#toxicology


References:

1. Mundy SW. Arsenic. In: Goldfrank's Toxicologic Emergencies, 10th ed, Hoffman RS, Lewin NA, Howland MA, et al (Eds), Mcgraw-Hill Education, New York 2015. p.1169. 

2.  Agency for Toxic Substances and Disease Registry. Toxicological Profile for Arsenic. U.S. Department of Health & Human Services, Public Health Service 2007. Available at: www.atsdr.cdc.gov/toxprofiles/tp.asp?id=22&tid=3 (Accessed on July 25, 2019).

3. Chhuttani P, Chopra J. Arsenic Poisoning. In: Handbook of Clinical Neurology: Intoxication of the Nervous System, part I, Vinken P, Bruyn G (Eds), North Holland, Amsterdam 1979. Vol 36, p.199.

Permissive hypoxemia

Q: The formula for 'Inspiratory Time' (IT) on the ventilator is the tidal volume divided by? (select one)

A) the inspiratory flow rate
B) the respiratory rate


Answer: A

Inspiratory time is the tidal volume divided by the inspiratory flow rate.

Clinical implication: Increasing IT increases the I; E ratio on the ventilator and induce the lung injury. Many times in the quest to achieve higher oxygenation,  clinicians increase the IT but the overall impact may be deleterious with an alveolar injury. Concept of "permissive hypoxemia" should be entertained in severe situations till hemodynamics are stable and organ functions are not jeopardized.

#ventilators


References:

1. He HW, Liu DW. Permissive hypoxemia/conservative oxygenation strategy: Dr. Jekyll or Mr. Hyde?. J Thorac Dis. 2016;8(5):748–750.

2. Casetti AV, Bartlett RH, Hirschl RB. Increasing inspiratory time exacerbates ventilator-induced lung injury during high-pressure/high-volume mechanical ventilation. Crit Care Med. 2002;30:2295–9.

MINS

Q: Pulmonary embolism (PE), sepsis, or cardioversion are considered the main reasons behind myocardial injury after noncardiac surgery (MINS)? (select one)

A) True
B) False


Answer: B

The main reason behind MINS is usually either underlying coronary artery disease CAD) or an acute thrombus. Perioperative MI due to PE, sepsis or cardioversion during surgery are not even considered as a cause in MINS. The most important thing to remember is that any troponin elevation in non-cardiac surgery implies myocardial injury or ischemia, and underlying CAD should be strongly considered and pursued.

#cardiology


References:

1. Botto F, Alonso-Coello P, Chan MT, et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology 2014; 120:564. 

2. Gualandro DM, Campos CA, Calderaro D, et al. Coronary plaque rupture in patients with myocardial infarction after noncardiac surgery: frequent and dangerous. Atherosclerosis 2012; 222:191. 

3. Sheth T, Natarajan MK, Hsieh V, et al. Incidence of thrombosis in perioperative and non-operative myocardial infarction. Br J Anaesth 2018; 120:725. 

4.  Landesberg G, Beattie WS, Mosseri M, et al. Perioperative myocardial infarction. Circulation 2009; 119:2936. 

5. Writing Committee for the VISION Study Investigators, Devereaux PJ, Biccard BM, et al. Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. JAMA 2017; 317:1642. 

6. Puelacher C, Lurati Buse G, Seeberger D, et al. Perioperative Myocardial Injury After Noncardiac Surgery: Incidence, Mortality, and Characterization. Circulation 2018; 137:1221.

single regimen antibiotics in acute acalculous cholecystitis

Q: Which of the following antibiotics can be used as an empiric single regimen in suspected acute acalculous cholecystitis?


A) Piperacillin-tazobactam
B) Cefepime
C) Ceftazidime
D) Metronidazole
E) Vancomycin


Answer: A

It is very important to cover broad-spectrum organisms appropriately for healthcare-associated intra-abdominal infections, for which acalculous cholecystitis is a prime example. Most of the time dual or triple coverage is initiated. As the focus on antibiotics stewardship is gaining momentum, appropriate single coverage should be considered. Local hospital antibiogram should be consulted. In most of the cases imipenem-cilastatin, meropenem, doripenem, and piperacillin-tazobactam are enough to cover most of the bugs. All other choices in the question require combination therapy.

#infectious-diseases
#hepatology


Reference:

1. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010; 50:133.

KS Rx

Q: 42 year old male with HIV is admitted to ICU with pneumonia. ID service in the list of their regimen also prescribed an anti-hypertensive. On your inquiry, they informed you that it may help to regress his Kaposi Sarcoma (KS). Which anti-hypertensive group of drugs found to be helpful in the treatment of Kaposi Sarcoma (KS)?

A) B-Blockers
B) Diuretics
C) Calcium Channel Blockers
D) Angiotensin-Converting-Enzyme-Inhibitors (ACE-I)
E) Alpha-blockers (Hydralazine)


Answer: A

Nonselective beta-adrenergic antagonist, Timolol has shown to enhance regression of KS lesions. This treatment is derived from the efficacy of another B-Blocker, Propranolol in the treatment of infantile hemangioma, a condition similar to KS. 

 Added pearl: Another unusual treatment of KS is the application of nicotine patch, as smoking is found to be associated with a reduced risk of KS.


#infectious-diseases


References:

1. McAllister SC, Hanson RS, Manion RD. Propranolol Decreases Proliferation of Endothelial Cells Transformed by Kaposi's Sarcoma-Associated Herpesvirus and Induces Lytic Viral Gene Expression. J Virol 2015; 89:11144. 

2. Goedert JJ, Scoppio BM, Pfeiffer R, et al. Treatment of classic Kaposi sarcoma with a nicotine dermal patch: a phase II clinical trial. J Eur Acad Dermatol Venereol 2008; 22:1101.

dose of succinylcholine in patients with myasthenia gravis

Q: The dose of succinylcholine in patients with myasthenia gravis (MG) should be? (select one) 

A) Increased 
B) Decreased


Answer: A

There is a misconception that the dose of succinylcholine should be decreased in myasthenia gravis to avoid the risk of hyperkalemia. Patients with myasthenia gravis are relatively resistant to succinylcholine. The dose should be adjusted to 2 mg/kg to stimulate the remaining acetylcholine receptors unaffected by the MG. Severe hyperkalemia rarely occurs with appropriate dosing

#pharmacology


Reference: 

Levitan R. Safety of succinylcholine in myasthenia gravis. Ann Emerg Med 2005; 45:225.

FIND ME

Q: "FIND ME" is a useful mnemonic for which patients?

Answer: FIND ME is a good mnemonic in the evaluation of an acutely agitated and delirious patient

Functional (psychiatric)
Infectious
Neurologic
Drugs

Metabolic
Endocrine

#neurology


Reference:

Ron Walls et. al. Rosen's Emergency Medicine - Concepts and Clinical Practice E-Book. Chapter 189.

LFT in ETOH liver

Q: Deficiency of which vitamin causes the high AST to ALT ratio in alcoholic hepatitis? 

A) Vitamin A
B) Vitamin B-6
C) Vitamin B-12
D) Vitamin C
E) Vitamin D


Answer: B

The synthesis of AST and ALT depends on the availability of vitamin B6 (pyridoxine), which is usually depleted in chronic alcoholics. ALT depends far more than AST on pyridoxine for its synthesis, and so usually stays low in these patients.

#hepatology


Reference:

Diehl AM, Potter J, Boitnott J, Van Duyn MA, Herlong HF, Mezey E. Relationship between pyridoxal 5′-phosphate deficiency and aminotransferase levels in alcoholic hepatitis. Gastroenterology. 1984;86:632–6.

PPV

Q: Pulse Pressure Variation (PPV) - an indicator of intravascular volume responsiveness is an unreliable indicator in patients with intra-abdominal hypertension (IAH)? (select one)

A) True
B) False


Answer: B

Pulse pressure is simply a difference between the systolic and the diastolic arterial blood pressure. Variation in pulse pressure (PPV) averaged over three or more breaths can be calculated by the formula

PPV = 100 x (PPmax – PPmin)/PPmean 

Many commercially available devices calculate it when an arterial line is present. PPV of 10 to 15 percent is found to be strongly associated with volume responsiveness, particularly in mechanically ventilated patients. 

It was postulated that raised IAH will distort PPV and will not be a reliable indicator of volume responsiveness in an intravascularly "dry" patient. But, studies have shown that PPV stays reliable despite IAH.


#hemodynamics


References:

1. Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med 2009; 37:2642.

2. De Backer D, Heenen S, Piagnerelli M, et al. Pulse pressure variations to predict fluid responsiveness: influence of tidal volume. Intensive Care Med 2005; 31:517.

3. Renner J, Gruenewald M, Quaden R, et al. Influence of increased intra-abdominal pressure on fluid responsiveness predicted by pulse pressure variation and stroke volume variation in a porcine model. Crit Care Med 2009; 37:650.

4. Jacques D, Bendjelid K, Duperret S, et al. Pulse pressure variation and stroke volume variation during increased intra-abdominal pressure: an experimental study. Crit Care 2011; 15:R33.

Class 4 hemorrhage

Q: In severe hemorrhage due to trauma, aggressive intravenous (IV) resuscitation should be initiated as soon as possible? (select one)

A) True
B) False 


Answer: B

Hemorrhage in trauma has been divided into 4 classes.

• Up to 15 percent of blood loss is called Class I hemorrhage. It constitutes minor hemodynamic changes
• 15 to 30 percent of blood loss is designated as Class II hemorrhage. With moderate hemodynamic changes, it makes skin cool and clammy, and delayed capillary refill
•  30 to 40 percent blood loss is under Class III hemorrhage. At this point changes in mental status is usually visible with paradox decrease in anxiety or pain
• More than 40 percent of blood loss constitutes Class 4 hemorrhage with a significant change in hemodynamics and mental status.

Treatment of hemorrhage with trauma is with blood products. Aggressive IV resuscitation beyond need increases the risk of coagulopathy from dilution of clotting factors and platelets. It may also aggravate hypothermia.

#trauma


References:

1. Brown JB, Cohen MJ, Minei JP, et al. Goal-directed resuscitation in the prehospital setting: a propensity-adjusted analysis. J Trauma Acute Care Surg 2013; 74:1207. 

2. Neal MD, Hoffman MK, Cuschieri J, et al. Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient: when a little goes a long way. J Trauma Acute Care Surg 2012; 72:892. 

3. Duchesne JC, Heaney J, Guidry C, et al. Diluting the benefits of hemostatic resuscitation: a multi-institutional analysis. J Trauma Acute Care Surg 2013; 75:76.

Hematuria in alcohol poisoning

Q: Hematuria is more common in? (select one) 

A) methanol poisoning 
B) ethylene glycol poisoning


Answer: B

Ethylene glycol toxicity can be divided into three phases: 

• CNS toxicity phase 
• Cardiopulmonary toxicity phase 
• Renal toxicity phase 

Although the presence of calcium oxalate crystals in the urine may appear very early in ethylene glycol toxicity - flank pain, oliguria, proteinuria, hematuria, crystalluria, and elevated serum BUN and creatinine happened very late in the poisoning.

#toxicology
#nephrology


Reference:

Agency for Toxic Substances and Disease Registry, 4770 Buford Hwy NE, Atlanta, GA 30341: 

https://www.atsdr.cdc.gov/csem/csem.asp?csem=12&po=9 (last retrieved on August 4, 2019)

LV thrombus

Q: After myocardial infarction which modality of transthoracic echo (TTE)  is preferred to detect left ventricular thrombus?

A) contrast 
B) non-contrast 


Answer: B

Many hospitals electronic system order TTE as non-contrast by default. The teaching point of this question is to highlight the addition of contrast to TTE.

Although the specificity of both non-contrast and contrast TTE is almost 100% to detect LV thrombus, the sensitivities are way low. The sensitivity to detect LV thrombus with non-contrast TTE is only 35 percent despite it is a thrombus, which is expected to be easily visualized. Adding contrast increases it up to 64 percent.


#cardiology
#procedures


Reference:

Srichai MB, Junor C, Rodriguez LL, et al. Clinical, imaging, and pathological characteristics of left ventricular thrombus: a comparison of contrast-enhanced magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography with surgical or pathological validation. Am Heart J 2006; 152:75.

bicarb and lactate

Q: All of the following occurs with rapid intravenous bolus of sodium bicarbonate except? 

A) increase PCO2 
B) decrease production of lactate 
C) lower ionized calcium 
D) expand extracellular space 
E) raise the serum sodium concentration 


 Answer: B

This question is designed to point out the dangers associated with overuse of "bicarb" boluses in ICU. 

Sodium bicarbonate should be used very judiciously to raise PH only when it goes below 7.1.

An IV bolus of bicarbonate does exactly the opposite for which it is used! - it accelerates the production of lactate! Acidemia is a naturally occurring body protection. It acts as a "brake" on lactic acid generation by inhibiting glycolysis, largely mediated by a reduction in the activity of the enzyme, phosphofructokinase. Resolving acidemia too fast accelerates the production of lactate. 


#acid-base


Reference:

Hood VL, Tannen RL. Protection of acid-base balance by pH regulation of acid production. N Engl J Med 1998; 339:819.

CVC complication

Q: Ventricular dysrhythmias and bundle branch block can be avoided during central line (CVC) placement by keeping guide wire not going deeper than? 


 Answer: 16 cm

Studies have shown that Ventricular dysrhythmias and bundle branch block during CVC placement can be avoided by not going deeper than 16 cm of guide wire particularly from R side.

 #procedures


References:

1. Boyd R, Saxe A, Phillips E. Effect of patient position upon success in placing central venous catheters. Am J Surg 1996; 172:380. 

2. Lefrant JY, Muller L, De La Coussaye JE, et al. Risk factors of failure and immediate complication of subclavian vein catheterization in critically ill patients. Intensive Care Med 2002; 28:1036.

florinef

Q: Fludrocortisone works via?

A) increase in blood volume
B) enhanced sensitivity of blood vessels to circulating catecholamines 
C) enhanced norepinephrine release from sympathetic neurons
D) all of the above
E) none of the above


Answer: D

Fludrocortisone is a synthetic mineralocorticoid commonly used in ICU patients particularly with renal failure, and presumed renal insufficiency. Its mechanism of action is through various mechanisms including an increase in blood volume, enhanced sensitivity of blood vessels to circulating catecholamines, and enhanced norepinephrine release from sympathetic neurons.

#hemodynamics
#pharmacology




References:


1. Davies IB, Bannister RG, Sever PS, Wilcox CS. Fludrocortisone in the treatment of postural hypotension: altered sensitivity to pressor agents [proceedings]. Br J Clin Pharmacol 1978; 6:444P.

2. Chobanian AV, Volicer L, Tifft CP, et al. Mineralocorticoid-induced hypertension in patients with orthostatic hypotension. N Engl J Med 1979; 301:68.

NSAID induced peptic ulcer

Q: 32 year old athletic male is admitted to ICU with bleeding peptic ulcer due to overuse of Non-Steroidal-Anti-Inflammatory-Drugs (NSAIDs). Which of the following regimen would be most effective? 

A) Proton Pump Inhibitors (PPIs) 
B) Histamine 2- Receptor-Blockers (H2-R-B) 
C) Combine PPI and H2-R-blocker 
D) Sucralfate 
E) Milk of Magnesia (MoM)


Answer: A

NSAID-induced peptic ulcers are best treated with PPIs. Interestingly and surprisingly combine PPI and H2-R-B failed to show any synergistic or added advantage. Similarly, all other modalities were found inferior to PPI in the treatment of NSAID induced peptic ulcer.

#gastroenterology
#pharmacology



References:


Yeomans ND, Tulassay Z, Juhász L, et al. A comparison of omeprazole with ranitidine for ulcers associated with nonsteroidal antiinflammatory drugs. Acid Suppression Trial: Ranitidine versus Omeprazole for NSAID-associated Ulcer Treatment (ASTRONAUT) Study Group. N Engl J Med 1998; 338:719. 

Blum AL, Bethge H, Bode JC, et al. Sucralfate in the treatment and prevention of gastric ulcer: multicentre double blind placebo controlled study. Gut 1990; 31:825.

SSRI effect of succinylcholine

Q: Selective serotonin reuptake inhibitors (SSRIs) tends to? (select one)

A) prolong the effect of succinylcholine
B) reduce the effect of succinylcholine


Answer: A

Succinylcholine is the most commonly used neuromuscular blockade (NMB) for intubation in ICU. A large number of patients admitted to ICU are now chronically on SSRIs. All SSRIs, in particular, fluoxetine and sertraline are inhibitors of cholinesterase in human serum and in the erythrocyte membrane. This tends to prolong the action for succinylcholine. 

#pharmacology
#procedures
#neurology


Reference:

Müller TC, Rocha JB, Morsch VM, et al. Antidepressants inhibit human acetylcholinesterase and butyrylcholinesterase activity. Biochim Biophys Acta 2002; 1587:92.

Fournier gangrene

Q: Fournier gangrene is more common in? (select one)

 A) male 
B) female


Answer: A

Necrotizing fasciitis of the perineum, popularly known as Fournier gangrene occurs due to a breach in the normal lining of the gastrointestinal (GI) or urethral mucosa. This may let a reader assume that this is more common amongst females but data suggests that it is more common in males. It quickly involves the anterior abdominal wall, gluteal muscles, scrotum, and the penile area.

#infectious-diseases


Reference: 

Ioannidis O, Kitsikosta L, Tatsis D, et al. Fournier's Gangrene: Lessons Learned from Multimodal and Multidisciplinary Management of Perineal Necrotizing Fasciitis. Front Surg. 2017;4:36. 

UAG

Q: Which one is the right formula for Urine An-ion Gap (UAG)?

A) Urine (Na + K - Cl)
B) Urine (Na + HCO3 - Cl)
C) Urine (Na - K + Cl)
D) Urine (Na + K + Cl)
E) Urine (Na + K - HCO3)


Answer: A

The UAG is not a perfect science but it helps in determining the cause of metabolic acidosis.

The UAG gets calculated as the difference between the sum of the urine sodium (Na) plus potassium (K) concentrations and the urine chloride (Cl) concentration (choices C & D wrong).

 UAG = Urine (Na + K - Cl)

The formula for the UAG is different from the formula to calculate the serum anion gap. The serum anion gap is the difference between the serum sodium and the sum of the serum chloride and bicarbonate concentrations (choices B & E are wrong).

The quantity of sodium and potassium absorbed by the gastrointestinal tract usually exceeds the quantity of absorbed chloride. Thus,  the UAG usually has a positive value between 20 and 90. The best utility to measure UAG is in large volume and/or chronic watery diarrhea, where the loss of sodium and potassium occurs in the stool without a parallel fall in chloride excretion. This results in negative UAG.

 If UAG stays positive with a hyperchloremic or nonanion gap metabolic acidosis, it indicates low or normal NH4 excretion, such as a distal RTA.

#acid-base-balance
#nephrology
#gastroenterology



References:


1. Batlle DC, Hizon M, Cohen E, et al. The use of the urinary anion gap in the diagnosis of hyperchloremic metabolic acidosis. N Engl J Med 1988; 318:594. 

 2. Oh M, Carroll HJ. Value and determinants of urine anion gap. Nephron 2002; 90:252. 

 3. Kim GH, Han JS, Kim YS, et al. Evaluation of urine acidification by urine anion gap and urine osmolal gap in chronic metabolic acidosis. Am J Kidney Dis 1996; 27:42.

MALA

Q: Mortality from Metformin associated lactic acidosis (MALA), if occurs, is about?



Answer: 50%

Lactic acidosis from metformin, known as MALA is very rare. It is reported at the incidence of only about 4 cases per 100K patient-years. But if it occurs, mortality is around 45-50%. 

The biggest risk factor is the underlying comorbidity with liver, kidney, heart or alcohol abuse. There is no antidote for MALA but hemodialysis is considered the best treatment modality.

#toxicology
#pharmacology


References:

1. Salpeter SR, Greyber E, Pasternak GA, Salpeter EE. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus. Cochrane Database Syst Rev 2010; :CD002967.

2. Seidowsky A, Nseir S, Houdret N, Fourrier F. Metformin-associated lactic acidosis: a prognostic and therapeutic study. Crit Care Med 2009; 37:2191.

3. Calello DP, Liu KD, Wiegand TJ, et al. Extracorporeal Treatment for Metformin Poisoning: Systematic Review and Recommendations From the Extracorporeal Treatments in Poisoning Workgroup. Crit Care Med 2015; 43:1716.

TB test in HIV

Q: Below which CD4 count tuberculin skin test stays negative in HIV patients?


Answer: 300 cells/microL

Tuberculin skin test is still a useful test in HIV patients with positive read at >5 mm. Tuberculin test depends upon the CD4 count so the test become meaningless below 300 cells/microL.

#infectious-diseases


Reference:

1. https://www.cdc.gov/mmwr/preview/mmwrhtml/00031075.htm

Nimbex & hypothermia

Q: Hypothermia? (select one)

A) prolongs the effect of cisatracurium
B) shortens the effect of cisatracurium


Answer:  A

Hypothermia slows down the Hoffmann elimination process, resulting in prolonging the effect of cisatracurium.

#pharmacology
#neurology


Reference:

Kisor DF, Schmith VD. Clinical pharmacokinetics of cisatracurium besilate. Clin Pharmacokinet 1999; 36:27.

Dose of Succinylcholine during intubation

Q: Dose of Succinylcholine during intubation should be based on? (select one) 

A) Ideal body weight 
B) Total body weight 


 Answer: B 

Succinylcholine is the most commonly used neuro-muscular blocker (NMB) in ICU for intubation. The recommended dose for intubation is 1.5 mg/kg intravenous (IV). It works within 60 seconds, and action lasts for 6 to 10 minutes. This dosage is based on total body weight. This becomes very important for proper intubation condition in obese as well as pregnant patients.


#procedure


References:

1. Naguib M, Samarkandi AH, El-Din ME, et al. The dose of succinylcholine required for excellent endotracheal intubating conditions. Anesth Analg 2006; 102:151. 

2. Lemmens HJ, Brodsky JB. The dose of succinylcholine in morbid obesity. Anesth Analg 2006; 102:438. 

3. Guay J, Grenier Y, Varin F. Clinical pharmacokinetics of neuromuscular relaxants in pregnancy. Clin Pharmacokinet 1998; 34:483. 

HES

Q: How you define Hypereosinophilic syndromes (HES)? 

 
Answer: Absolute Eosinophilic Count ≥1500/microL on two occasions ≥1 month apart plus organ dysfunction attributable to eosinophilia. An important distinction to remember is if the clinical condition with hypereosinophilia can be explained by any other mechanism should not be labeled as HES. 

A complete description of this syndrome is beyond the scope of this pearl, but we strongly suggest to read this article:

Hypereosinophilic syndromes

Florence E Roufosse, Michel Goldman & Elie Cogan 

Orphanet Journal of Rare Diseases - volume 2, Article number: 37 (2007)


#immunology
#hematology


Reference: 

 Valent P, Klion AD, Horny HP, et al. Contemporary consensus proposal on criteria and classification of eosinophilic disorders and related syndromes. J Allergy Clin Immunol 2012; 130:607.

ketamine

Q: All of the following are possible effects of Ketamine except?

A) 'Out of body' experience
B) Amnesia 
C) Dilatation of pupils 
D) Increased muscle tone 
E) Absence-like effect


Answer:  CNS effects of Ketamine include a wide variety of symptoms. It includes agitation, dissociation, inability to sense pain, hallucination, ataxia, nystagmus. In abuse and with emergence reactions, patients may also experience extreme agitation, fear, and psychiatric disturbance. The typical presentation of ketamine abusers who present for medical evaluation is impaired consciousness, vivid dreams, "out of body" experiences, illusions, euphoria, and fear. It also causes amnesia, dilatation of pupils, increased muscle tone, and absence-like effect.

In severe overdose, ketamine may cause coma.


#neurology
#pharmacology


Reference:

Green SM, Li J. Ketamine in adults: what emergency physicians need to know about patient selection and emergence reactions. Acad Emerg Med 2000; 7:278.

acyclovir

Q: Which drug is more prone to cause acute kidney dysfunction? (select one) 

 A) IV Acyclovir 
 B) IV Ganciclovir


 Answer: A 

 Acyclovir has low solubility and gets rapidly excreted in the urine. In a hypovolemic patient, deposition of acyclovir crystals in the tubules occurs quickly, causing an intratubular obstruction and interstitial inflammation. Ganciclovir does the same thing but with lesser intensity. Patients may complain of kidney stones like symptoms. The best prevention is IV hydration, adequate urine output @ 75 mL/hour and slow infusion of the drug.

#nephrology
#pharmacology


References:

Sawyer MH, Webb DE, Balow JE, Straus SE. Acyclovir-induced renal failure. Clinical course and histology. Am J Med 1988; 84:1067.

pain of biliary colic and acute cholecystitis

Q: How a pain of biliary colic and acute cholecystitis can be differentiated?


Answer:  Pain in biliary colic is described as dull discomfort but of high intensity. It usually stayed in the parameter of  Right Upper Quadrant (RUQ) or epigastrium and may be associated with nausea, vomiting, and diaphoresis. Most importantly, it lasts for 30 minutes, plateau within one hour, and other abdominal exam remains normal.

Pain in acute cholecystitis stays for more than 4 to 6 hours in RUQ or epigastric area and accompanied by fever. Associated abdominal exam shows guarding and positive Murphy's sign.

#physical-exam
#hepatology


Reference:

C. David Naylor. Physical Examination of the Liver. AMA. 1994;271(23):1859-1865

Auto PEEP

Q: Which one is correct for Auto-PEEP? (select one)

A) Auto-PEEP = end-expiratory alveolar pressure - applied PEEP
B) Auto-PEEP = end-inspiratory alveolar pressure - applied PEEP


Answer: A

Positive end-expiratory pressure is called PEEP. It is applied from the ventilator to avoid a complete collapse of alveoli at the end of the expiration. But less than the desired volume of expired air before the start of the next breath may result in air trapping and increases alveolar pressure at the end of expiration. This is called auto-PEEP. It can have life-threatening consequences if not addressed before time.

Auto-PEEP can be quantified at the bedside by applying a breath-hold at end-expiratory and calibrating the airway pressure while the ventilator stays at breath-hold. Taking off applied PEEP from this value gives the Auto-PEEP.

#ventilators
#pulmonary


Reference:

John J. Marini. Dynamic Hyperinflation and Auto–Positive End-Expiratory Pressure Lessons Learned over 30 Years. AJRCCM. Vol. 184, No. 7 | Oct 01, 2011

meningitis & encephalitis

Q: How the difference between encephalitis and meningitis can be established?

Answer: In patients with meningitis cerebral function remains normal though seizure may occur followed by post-ictal changes. In contrast, patients with encephalitis develop deficit with the brain function from altered mental status to the motor or sensory deficits (such as hemiparesis, flaccid paralysis or paresthesias). It may also include speech or movement disorders. Encephalitis may also present as behavior or personality changes. 

#neurology



Reference:

Matthew Short. Meningitis and encephalitis. Sage Journal. Volume: 9 issue: 10, page(s): 589-596