Tuesday, August 31, 2010

Q; 52 year old female went into supraventricular tachycardia. While you call for Adenosine at bedside, clinical pharmacist inform you that patient is on chronic Aggrenox for her stroke?

Answer: Aggrenox is the combination of Aspirin and extended release Dipyridamole. Dipyridamole potentiates the action of adenosine so the lower doses (usually half) should be given.

Give only half of recommended dose of Adenosine.

Monday, August 30, 2010

Q; Why Haldol (Haloperidol) should be use with caution in burn patients?

Answer: Neuropsychiatric complications are commonly seen in major burn patients. Haloperidol is frequently used to treat severe psychopathic behavior. There could be an increase tendency of severe muscle rigidity - an extrapyramidal side effect of the agent - in burn patients. Haloperidol causes a relative imbalance of dopaminergic and cholinergic neuronal activity in the basal ganglia with a relative increase in cholinergic activity being responsible for EPS. The burn patient may be more prone to extrapyramidal symptoms because of increased sensitivity of skeletal muscle neuromuscular junctions to acetylcholine after thermal injury.


Haloperidol Complications in Burn Patients. Journal of Burn Care & Rehabilitation. 8(4):269-273, July/August 1987

Sunday, August 29, 2010

Q: Does Diuresis help in (Transfusion-related acute lung injury (TRALI)?

Answer: Not really

TRALI is associated with microvascular damage and not fluid overload, so diuretics are not really helpful and actually not recommended. Since the pulmonary edema in TRALI is not related to fluid overload or cardiac dysfunction, it is logical that maintenance of adequate circulating volume is more beneficial. Ventilatory assistance and circulatory support are the mainstays of treatment of TRALI. Diuretic use may be detrimental and could lead to hypotension.

Saturday, August 28, 2010

Q: What could be the supporting finding on lab in (Transfusion-related acute lung injury (TRALI)?

Answer: Laboratory findings may include unexpected haemoconcentration and a sudden fall in serum albumin. As in other causes of acute alveolar capillary leak, the pulmonary exudate in TRALI has a high albumin content. Peripheral blood neutropenia has been reported but neutrophilia is more common.


The pathology of transfusion-related acute lung injury. Am J Clin Pathol 1999; 112: 216–21

Friday, August 27, 2010

Q: One purpose of administrating local anesthesia (lidocaine) during Arterial line placement is to relieve pain for patient. What other purpose does it serve?

Answer: A subcutaneous infiltration of anesthetic around the puncture site also help in reducing vessel spasm beside providing pain relief to a patient.

Thursday, August 26, 2010

Editors' note: On August 21, 2010, we posted a pearl with conclusion that Norepinephrine is more stable in D5W rather than in NS. We received following study as counter argument from "Zach"!

Can J Anaesth. 2008 Mar;55(3):163-7.

Stability of norepinephrine infusions prepared in dextrose and normal saline solutions.

Tremblay M, Lessard MR, Trépanier CA, Nicole PC, Nadeau L, Turcotte G. -Department of Anesthesiology, Centre hospitalier affilié universitaire de Québec, Université Laval, Québec City, Québec, Canada.

PURPOSE: Norepinephrine (NE) infusions are commonly used in the intensive care unit and in the operating room. Data on long term stability of NE solutions are lacking. This prospective study was designed to evaluate the stability of NE, in dextrose (5%) in water (D5W) and in normal saline (NS) solutions, for a period up to seven days.

METHODS: We prepared norepinephrine solutions in quadruplicate, by aseptically diluting 1 mg NE in 250 mL of D5W or NS and 4 mg NE in 250 mL of D5W or NS (final concentrations, 4 microg x mL(-1) and 16 micro x mL(-1), respectively) and stored the solutions at room temperature under ambient light. We sampled the solutions, in duplicate, at times 0, 24, 48, 72, 120, and 168 hr and stored them at -80 degrees C for later assay. Norepinephrine concentrations were measured by high-performance liquid chromatography with electrochemical detection (coefficient of variation 4.6%). Statistical analysis was done by nonparametric, repeated measures ANOVA (Friedman test).

RESULTS: There was no significant decrease in NE concentration for either, NE 4 microg x mL(-1) in D5W or NS (P = 0.09 and 0.11, respectively) or for NE 16 microg x mL(-1) in D5W or NS (P = 0.18 and 0.40, respectively). The ratios of NE concentration at 168 hr, compared to baseline, were 95.7% and 96.4%, for NE 4 microg x mL(-1) in D5W and NS, respectively, and 104.5% and 96.4%, for NE 16 microg x mL(-1) in D5W and NS, respectively.

CONCLUSION: Norepinephrine solutions, in concentrations commonly used in the clinical setting, are chemically stable for seven days, at room temperature and under ambient light, when diluted either in D5W or NS.

Wednesday, August 25, 2010

Soda-bicarb to prevent contrast induced nephropathy

Q: How you write the order for soda bicarbonate infusion in preventing contrast induced nephropathy ?

A: Use 154meq/L of sodium bicarbonate (3 amps) in 1 litre of D5W.Give 3ml/kg/hr one hr prior to the exam.Give 1ml/kg/hr during the exam and for 6 hours after the exam.

Tuesday, August 24, 2010

Q; Succinylcholine is contraindicated (relatively) for intubation in which poisoining?

Answer: Organophosphate poisoning.Organophosphate may potentiate effects of succinylcholine. Succinylcholine is relatively contraindicated in Organophosphate poisoining

Monday, August 23, 2010

Critical Care Humor

Never use needle on a patient if you have an empty stomach and a full bladder!

(you never know what procedure may take)

Sunday, August 22, 2010

Q; 24 year old male with no past medical history presented to ER with SVT (Supraventricular Tachycardia). Heart rate is 210. Patient was given Adenosine and went into ventricular fibrillation. CPR started and converted back to NSR (normal sinus rhythm) with cardioversion. What is your first thought?

Answer: Wolff-Parkinson-White syndrome (WPW)

People with WPW have an accessory pathway that connects the atria and the ventricles, in addition to the AV node. This accessory pathway is known as the bundle of Kent. This accessory pathway may conduct electrical activity at a significantly higher rate than the AV node particularly when it is blocked and may degenerate into venticular fibrillation.

Adenosine and other AV node blockers should be avoided including calcium channel blockers and beta blockers. Patients with atrial fibrillation and rapid ventricular response are better treated with procainamide or cardioversion in hemodynamic instability

Saturday, August 21, 2010


NOREPINEPHRINE (LEVOPHED) drip should be prepared in dextrose containing solution (D-5). NOREPINEPHRINE (LEVOPHED) is less stable in normal saline and loose its potency from oxidation over hours. Dextrose containg solution is preferred as the dextrose protects against oxidation of the norepinephrine and keep it active and stable.

Friday, August 20, 2010

Q; 24 year old female 2 weeks post partum developed severe headache of one week followed by seizure. While you start workup what would be your presumptive diagnosis and line of mangement?

Answer: Postpartum cerebral vasospasm would be high on list

Cerebral angiography or Magnetic resonance imaging/angiography should be perform as soon as possible to rule out vasospasm. IV fluid should be started with atleast 125 cc/hour and goal to keep BP high. Treatment consist of hyperosmolar, hypervolemic therapy and nimodipine.

Thursday, August 19, 2010

Neuro-Critical Care

Q; Beside it's use in prevention of vasospasm in Subarachnoid hemorrhage - what could be the other less known uses of Nimodipine?

Though not as effective but it can be use as an alternative or an adjuvent to magnesium for seizure prophylaxis in women with severe preeclampsia.

Also it has an adjuvent value in the treatment of intractable seizure.

Please note that FDA warned against using Nimodipine capsules as IV.

Nimodipine has been originally designed for the treatment of high blood pressure but is not used for this indication anymore.

Wednesday, August 18, 2010


Q; Do you know the meaning of word "sepsis" (word origin)?

Answer: Sepsis is derived from a Greek word "sepo" meaning “I rot”. Historically first time described in the poems of Homer.


Historical perspective of the word Sepsis - Intensive Care Medicine(2006), Volume 32, Number 12, page 2077

Tuesday, August 17, 2010

Q; After successful completion of Transjugular Intrahepatic Porto-systemic Shunt (TIPS) for variceal bleeding - hepatic encephalopathy __________ ?

A) tends to get better
B) tends to get worse
C) It has nothing to do with TIPS

Answer is B

Hepatic encephalopathy tends to get worse after successful completion of TIPS as due to shunting, blood flow to the liver is reduced, which might result in increase toxic substances reaching the brain without being metabolized first by the liver. It can be treated medically such as diet, lactulose or by narrowing of the shunt by insertion of a reducing stent.

Monday, August 16, 2010

Back to Basic - MoA ACE inhibitors

Sunday, August 15, 2010

Drug interaction

Q: Which 2 commonly used cardiac medicines may interact negatively?

Answer: Aspirin and ACE inhibitors

Effects of ACE inhibitors are attenuated by aspirin.

ACE inhibitors decrease angiotensin II production and inhibit breakdown of bradykinin. Bradykinin stimulates vasodilator prostaglandins via a cyclo-oxygenase–dependent pathway.

Aspirin inhibits cyclo-oxygenase-1 (COX-1), thereby reducing synthesis of vasodilatory prostaglandins.

Above interaction may be of more academic interest. In clinical practice - there are no firm guidelines for use of both drugs simultaneously.

Saturday, August 14, 2010

New Brain Death Guidelines!

The American Academy of Neurology has released new guidelines for determining brain death in adults. The recommendations provide step-by-step instructions to help guide clinical decision making.

The guidelines are published in the June 8 issue of Neurology.

Among other the notable thing is that more than 1 exam is not required in the new brain death guidelines. Clinicians usually perform 2 exams. In new guidelines one time brain death exam is sufficient.

Click here to get full update.

Friday, August 13, 2010

On Friday the 13th!

Q: What is the possible explanation behind Lazarus Syndrome?

Answer: Lazarus Syndrome is a generic term use in hospitals when patient shows sign of life after clinically declared dead, like a patient that develops vital signs after cessation of resusitative efforts or organ-donation team arrives to find a live person.

Possible explanation is that a chief factor is the buildup of pressure in the chest as a result of cardiopulmonary resuscitation (CPR). The relaxation of pressure after resuscitation efforts have ended is thought to allow the heart to expand, triggering the heart's electrical impulses and restarting the heartbeat.

The syndome is named after bible story in which Jesus brought back to life a dead person named Lazarus from his tomb. Term became very popular after publication of book "The Lazarus syndrome: Burial alive and other horrors of the undead" (Rodney Davies - 1978).

In recent years, 'Lazarus Syndrome' has also been use for HIV/AIDS patients who feel having new chance of living with new HIV medications.

Thursday, August 12, 2010

Q: 24 year old male presented with syncope. Patient has family history of sudden cardiac deaths in family and you strongly suspect Brugada syndrome. Which drug can be use to elicit specific EKG patterns for diagnosis of Brugada syndrome?

Answer: Flecainide

The Brugada syndrome is a genetic disorder characterised by abnormal EKG findings and an increased risk of sudden cardiac death particularly in young men without known underlying cardiac disease.

Brugada syndrome can be detected by observing characteristic patterns on an EKG, which may be present all the time, or in clinical suspicion can be elicited by the administration of Class IC antiarrhythmic drugs (like flecainide) that blocks sodium channels and causing appearance of ECG abnormalities.

Review on Brugada Syndrome at emedicine.com

Wednesday, August 11, 2010

The End of the Code

"When I was but an EMT lad in an ED I witnessed something I’ve incorporated into my own practice, and I think every doc should do it. When it’s ‘that time’, time to stop the resuscitation, in every instance I say something along the lines of “Okay, we’ve been coding this person for xx minutes, and there’s been (brief summary): does anyone here want to do anything else? If so, tell me now”. This does two things which are important for everyone in the room who isn’t dead: it makes them part of the decision making process, and it empowers them to very easily object should they wish, for whatever reason, to continue. “I’d like to give some (whatever)” is then totally fine, and they’re not having to object in a vague way that they’re not done yet with what can be a terrifically personal struggle to save someone none of us has met, or knows as anyone other than a patient. We give the whatever, and after a while, given the persistence of death, I’ll give my speech as many times as it takes (so far, twice has been all, but I’d be perfectly willing to go on for a long time), because it’s important for everyone involved to acknowledge that they did what they could, and to be comfortable with stopping.

Codes end, very occasionally with a happy outcome, more often than not with a patient under a sheet, but the people who were there need to feel like they had a chance to do all they could.

Death is forever, and so is guilt; I want to make certain the dead don’t take the living with them"

Taken from blog of GruntDoc

Tuesday, August 10, 2010

Q: Describe the significance of "Herald Bleeding" in Primary aortoenteric fistula (PAEF)?

Answer: One of the known characteristic of PAEF is of a "herald" bleeding followed hours, days, or even weeks later by a catastrophic bleeding. The herald bleeding is the result of a small fistula tamponaded by thrombus formation. If the fistula continues to expand or the occluding thrombus is removed, massive hemorrhage results.

Clinical significance: This is probably the only window of opportunity to salvage the patient before massive bleed takes over. Emergency exploratory laparotomy should be done as soon as the diagnosis is considered clinically. Mortality is 100% without surgical intervention.

Communications between the aorta and the intestine resulting from disease at either site are referred to as primary aortoenteric fistulas. Causes include untreated aortic aneurysm, infectious aortitis, erosion of the intestine by prosthetic vascular grafts, esophageal cancer etc. Refer other texts for more detailed descriptions.

Monday, August 9, 2010

Q: Whats the best measure of titrating Atropine drip in Organophosphate poisoning?

Answer: Control of hypersecretions served as the best monitoring parameter for titration of the drip rate. Organophosphate (OP) toxicity itself is a clinical diagnosis. There is no clinical lab value which can be followed except for above clinical objective finding. Following mnemonic can be used to remember the muscarinic effects of organophosphates.

SLUDGE: salivation, lacrimation, urination, diarrhea, GI upset, emesis

DUMBELS: diaphoresis and diarrhea; urination; miosis; bradycardia, bronchospasm, bronchorrhea; emesis; excess lacrimation; and salivation.

Sunday, August 8, 2010

Q: Which vitamin deficiency may cause life threatening lactic acidosis?

Answer: Thiamine (Vitamin B1) deficiency

Thiamine is part of the pyruvate-dehydrogenase (PDH) complex. Its deficiency inhibits pyruvate entry into mitochondria.

Clinical implication: It is important to add Thiamine on patients requring long term parentral nutrition (TPN).

Reference: Click to get references

Thiamine deficiency as a cause of life threatening lactic acidosis in total parenteral nutrition - Klin Wochenschr. 1991;69 Suppl 26:193-5.

Metabolic acidosis and thiamine deficiency - Mayo clinic Proceedings, March 1999 vol. 74 no. 3 259-263

Severe Lactic Acidosis Related to Acute Thiamine Deficiency - Journal of Parenteral and Enteral Nutrition, Vol. 15, No. 1, 105-109 (1991)

Saturday, August 7, 2010

Q: Despite being an old player Sucralfate is still very well indicated in stress ulcer prophylaxis. What is the mechanism of action of sucralfate?

Answer: Sucralfate act by multiple mechanisms

1. Sucralfate acting locally that in an acidic environment , reacts with hydrochloric acid in the stomach to form a cross-linking, viscous, paste-like material capable of acting as an acid buffer for as long as 6 to 8 hours after a single dose.
2. It also attaches to proteins on the surface of ulcers, such as albumin and fibrinogen, to form stable insoluble complexes. These complexes serve as protective barriers at the ulcer surface, preventing further damage from acid, pepsin, and bile.

3. It prevents back diffusion of hydrogen ions.

4. It adsorbs both pepsin and bile acids.

5. Sucralfate also stimulates the increase of prostaglandin E2, epidermal growth factors (EGF), bFGF, and gastric mucus.

Friday, August 6, 2010

Q: How Dexilant (Dexlansoprazole) is different from other PPIs (Proton Pump Inhibitors)?

Answer: Dexilant has a DUAL DELAYED RELEASE mechanism. It contains two different types of granules for two releases of medicine. Dexilant works by releasing one shift of medicine within an hour of taking it to decrease the amount of acid in stomach. Around 4–5 hours later, Dexilant releases a second shift of medicine.

How much advantage does it provide over other PPIs has yet to be determine in independent studies.

Thursday, August 5, 2010

Thursday August 5, 2010

Q: What is the difference between available synthetic thyroid hormone replacement and natural thyroid hormone replacement in market?

Answer: Synthetic thyroid hormone contains T4 only and is therefore largely ineffective for patients unable to convert T4 to T3. Also some patients may develop allergy to synthetic thyroid hormone.

Natural thyroid treatments hormones are still available. Armour Thyroid is the most popular brand available and is a natural, porcine-derived thyroid replacement containing both T4 and T3. The ratio of Thyroid T4 to T3 is 4.22:1.

Armour thyroid is available in strengts as grains (1/4, 1/2, 1 grains).

1 grain of Armour is approximately equal to 100 mcg of levothyroxine

Wednesday, August 4, 2010

Q: Why Prealbumin is called Prealbumin?

Answer: Prealbumin is called prealbumin because it ran faster than albumins on electrophoresis gels in contrast to general belief that its a precursor of albumin. It should not be confused with albumin.

The right name for Prealbumin is Transthyretin (TTR). TTR is a serum and cerebrospinal fluid carrier of the thyroid hormone thyroxine (T4) and retinol. This is how transthyretin gained its name, transports thyroxine and retinol.

Nutritional status can be assessed by measuring concentrations of prealbumin in the blood. Prealbumin is preferred because of its shorter half-life, although this means that its concentration more closely reflects recent dietary intake rather than overall nutritional status

Tuesday, August 3, 2010

Q: In human body for measurement , each 1 g/dL decrease of albumin will raise the serum Calcium by what level?

Answer: Each 1 g/dL decrease of albumin raises the serum calcium (Ca) level by 0.8 mg/dL in human body. Remember the formula for calcium correction from internship days?

Corrected calcium (mg/dL) = measured total Ca (mg/dL) + 0.8 (4.0 - serum albumin [g/dL])

Monday, August 2, 2010

Pleural calcification in asbestos exposure

Pleural calcification occurs in about 50% with asbestos-related disease, especially along the diaphragmatic pleura. (White arrow)The overall appearance of the plaque has been likened to a holly leaf. (Black arrows) point to many of the calcified pleural plaques.

Sunday, August 1, 2010

Q: 78 year old male presented with severe abdominal pain. Patient is taking huge amount of over the counter NSAIDs and you suspect perforated peptic ulcer. As an initial workup you ordered upright KUB. Looking at portable screen of technician you didn't see any free air. What should be your next step?

Answer: Take a left lateral decubitus film.

Plain x-rays of the abdomen with the patient in the upright position have been used in diagnosing perforated ulcer. However, in 30% to 50% of patients, the x-ray may be negative for free air, particularly in the elderly. A left lateral decubitus film has been shown to be most sensitive in detecting pneumoperitoneum. Placing the patient in the upright or left lateral decubitus position for 10 minutes before taking the x-ray may help detect the condition. Similarly, use of water-soluble contrast medium with an upper gastrointestinal tract series or computed tomography scan may increase the diagnostic yield.