Q: 52 year old male developed intracranial hemorrhage after receiving thrombolytic therapy for CVA. What is the treatment?
Answer: Transfusion of cryoprecipitate.
Prepare for administration of 6 to 8 units of cryoprecipitate containing factor VIII. It is not a bad idea to also adminster 6 to 8 units of platelets.
Monday, January 31, 2011
Sunday, January 30, 2011
Q: What is Delta-p value in extremity's Compartment syndrome?
A; Delta-p is diastolic blood pressure minus intracompartmental pressure. It is a measure of perfusion pressure. Delta-p measurements of less than 30 mm Hg is used for fasciotomy. Other clinical situations should be taken into consideration.
A; Delta-p is diastolic blood pressure minus intracompartmental pressure. It is a measure of perfusion pressure. Delta-p measurements of less than 30 mm Hg is used for fasciotomy. Other clinical situations should be taken into consideration.
Saturday, January 29, 2011
Q: What is Captopril Test ?
A; It is a simple poor man's test to diagnose renal cause for hypertension. It has high sensitivity but a low specificity.
In this test, the baseline level of renin in the blood is determined by drawing blood. Then an oral dose of captopril is given and, after an hour, the plasma renin level is determined again. Because captopril blocks the activity of one of the proteins that renin works on, the blood pressure should fall. This decrease in blood pressure is detected by both kidneys, but especially by the one that has a blocked blood supply. This kidney responds by secreting a large amount of renin. Thus an exaggerated renin response after the dose of captopril is suggestive of a renovascular hypertension. hypertension.
The captopril test for identifying renovascular disease in hypertensive patients. - Am J Med. 1986 Apr;80(4):633-44.
A; It is a simple poor man's test to diagnose renal cause for hypertension. It has high sensitivity but a low specificity.
In this test, the baseline level of renin in the blood is determined by drawing blood. Then an oral dose of captopril is given and, after an hour, the plasma renin level is determined again. Because captopril blocks the activity of one of the proteins that renin works on, the blood pressure should fall. This decrease in blood pressure is detected by both kidneys, but especially by the one that has a blocked blood supply. This kidney responds by secreting a large amount of renin. Thus an exaggerated renin response after the dose of captopril is suggestive of a renovascular hypertension. hypertension.
The captopril test for identifying renovascular disease in hypertensive patients. - Am J Med. 1986 Apr;80(4):633-44.
Friday, January 28, 2011
Q: What is the 'rule of thumb' of Esmolol dose in heart rate (HR) control of Atrial fibrillation?
A; Following intravenous infusion of esmolol for 30 minutes with dose of:
- 50 mcg/kg per minute HR drop by 8%
- 100 mcg/kg per minute HR drop by 11%
- 150 mcg/kg per minute HR drop by 14%
- 200 and above mcg/kg per minute HR drop by 15%
Related Previous Pearl: Esmolol is metabolised in...?
Source: AHFS Drug Information. (CR) Copyright, 1959-2010, Selected Revisions January 2010. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814
Thursday, January 27, 2011
Wednesday, January 26, 2011
Q: Which of the following medicines can cause "Red Man Syndrome"?
A) Ciprofloxacin,
B) Amphotericin B,
C) Rifampcin
D) Vancomycin
E) All of the above
Answer: All of the above
Antibiotics such as ciprofloxacin, amphotericin B and rifampcin can also potentially cause red man syndrome beside vancomycin. Like vancomycin, they are capable of causing direct degranulation of mast cells and basophils. Red man syndrome is amplified if these antibiotics are combined with vancomycin or with each other. Red man syndrome is also magnified in patients receiving vancomycin and opioid analgesics, muscle relaxants, or contrast dye because these drugs can also stimulate histamine release.
A) Ciprofloxacin,
B) Amphotericin B,
C) Rifampcin
D) Vancomycin
E) All of the above
Answer: All of the above
Antibiotics such as ciprofloxacin, amphotericin B and rifampcin can also potentially cause red man syndrome beside vancomycin. Like vancomycin, they are capable of causing direct degranulation of mast cells and basophils. Red man syndrome is amplified if these antibiotics are combined with vancomycin or with each other. Red man syndrome is also magnified in patients receiving vancomycin and opioid analgesics, muscle relaxants, or contrast dye because these drugs can also stimulate histamine release.
Tuesday, January 25, 2011
Monday, January 24, 2011
Q: 53 year old male with ESRD (Renal failure) is in ICU. Nurse ask you to write some prn medicine for BP control. Patient is already on high dose B-blocker. You write for IV Hydralazine. one hour after administration of Hydralazine you have been asked to evaluate patient for mental status change?
Answer: In patients particularly with renal failure/uremia hydralazine may produce a marked decrease in blood pressure, resulting in central reactions such as anxiety, delirium, disorientation, depression, and coma.
Also Hydralazine is a cerebral vasodilator and is known to increase intracranial pressure which, together with its effect upon systemic blood pressure, reduces the cerebral perfusion pressure.
Answer: In patients particularly with renal failure/uremia hydralazine may produce a marked decrease in blood pressure, resulting in central reactions such as anxiety, delirium, disorientation, depression, and coma.
Also Hydralazine is a cerebral vasodilator and is known to increase intracranial pressure which, together with its effect upon systemic blood pressure, reduces the cerebral perfusion pressure.
Sunday, January 23, 2011
Q: What is the difference between "Blue" and "Green" acapella®?
Answer: Acapella® is a vibratory Positive Expiratory Pressure (PEP) Therapy System which also combines the benefits of airway vibrations to mobilize pulmonary secretions.
PEP devices work by having a one way valve that creates resistance when the patient breathes out against it. With PEP therapy, the pressure difference that occurs when a patient breathes out allows the lungs to fill with additional air, which in turn will push the mucus out as the lungs try to return to an equilibrant volume.
Patient inhales deeply with a 3 to 4 second breath hold, alternating with normal breathing. Inspiratory to expiratory ratio is kept around 1:3 to 1:4. After 5-10 exhalations of alternating regular/deep breaths, patient is asked to cough.
Blue Acapella - has low expired lung volumes with less than 15 lpm for 3 seconds.
Green Acapella - has high expired lung volumes with more than 15 lpm for 3 seconds.
Answer: Acapella® is a vibratory Positive Expiratory Pressure (PEP) Therapy System which also combines the benefits of airway vibrations to mobilize pulmonary secretions.
PEP devices work by having a one way valve that creates resistance when the patient breathes out against it. With PEP therapy, the pressure difference that occurs when a patient breathes out allows the lungs to fill with additional air, which in turn will push the mucus out as the lungs try to return to an equilibrant volume.
Patient inhales deeply with a 3 to 4 second breath hold, alternating with normal breathing. Inspiratory to expiratory ratio is kept around 1:3 to 1:4. After 5-10 exhalations of alternating regular/deep breaths, patient is asked to cough.
Blue Acapella - has low expired lung volumes with less than 15 lpm for 3 seconds.
Green Acapella - has high expired lung volumes with more than 15 lpm for 3 seconds.
Saturday, January 22, 2011
Q: 36 year old male is admitted to ICU with severe metabolic acidosis. You suspect sepsis and ordered pan-culture. While reviewing lab you see that urine screen is reported with calcium oxalate crystals. What is your concern?
Answer: Ethylene glycol poisoning
Ethylene glycol’s major toxicity is a result of it’s metabolites: glycoaldehyde, oxalic acid, glycolic acid, and glyoxylate. Oxalic acid combines with calcium to form calcium oxalate crystals.
Answer: Ethylene glycol poisoning
Ethylene glycol’s major toxicity is a result of it’s metabolites: glycoaldehyde, oxalic acid, glycolic acid, and glyoxylate. Oxalic acid combines with calcium to form calcium oxalate crystals.
Friday, January 21, 2011
Q: An extremely vasculopath patient (almost impossible to obtain central line) presented to ER with organophosphate poisoning. Till Vascular team access vessel what could be an alternate route of Atropine in its symptomatic treatment?
Answer: Sublingual
Answer: Sublingual
Rajpal S, Ali R, Bhatnagar A, Bhandari SK, Mittal G. Clinical and bioavailability studies of sublingually administered atropine sulfate. Am J Emerg Med. Feb 2010;28(2):143-50.
Thursday, January 20, 2011
Q: 69 year old male with history of COPD is now recommended to have aerosolized colistin for his pulmonary infection. Which simultaneous order may benefit him?
Answer: Administration of aerosolized colistin may cause bronchospasm, especially in patients with previous related history. Orders to give bronchodilators prior to administration of colistin may prevent the problem.
Answer: Administration of aerosolized colistin may cause bronchospasm, especially in patients with previous related history. Orders to give bronchodilators prior to administration of colistin may prevent the problem.
Wednesday, January 19, 2011
Q: Can you do any lab test for restless leg syndrome (RLS)?
Answer: Yes! Ferritin level
Five major causes described for RLS
1. Iron Deficiency: Even without significant anemia, serum ferritin levels below 50 ng per mL can exacerbate RLS symptoms. Serum ferritin levels is now considered essential in the workup of RLS.
2. Neurologic: in association with spinal cord and peripheral nerve lesions.
3. Pregnancy: RLS may affects women during pregnancy. Symptoms usually subside within a few weeks postpartum.
4. Uremia: RLS occurs in up to 50 percent of patients with end-stage renal failure and subside after renal transplantation.
5. Drug-Induced like: tricyclic antidepressants, SSRIs, lithium, Caffeine and dopamine antagonists.
Answer: Yes! Ferritin level
Five major causes described for RLS
1. Iron Deficiency: Even without significant anemia, serum ferritin levels below 50 ng per mL can exacerbate RLS symptoms. Serum ferritin levels is now considered essential in the workup of RLS.
2. Neurologic: in association with spinal cord and peripheral nerve lesions.
3. Pregnancy: RLS may affects women during pregnancy. Symptoms usually subside within a few weeks postpartum.
4. Uremia: RLS occurs in up to 50 percent of patients with end-stage renal failure and subside after renal transplantation.
5. Drug-Induced like: tricyclic antidepressants, SSRIs, lithium, Caffeine and dopamine antagonists.
Tuesday, January 18, 2011
Bedside trick - suspecting tracheal aspiration!!
One quick method of suspecting tracheal aspiration or atleast ruling out tracheal aspiration is checking glucose concentration by regular bedside glucose meters. A glucose concentration of more than 20 mg/dl of bloodless tracheal aspirate doesn't confirm but atleast enhance the suspicion of tracheal aspiration.
Though literature is full of conflicting data for this method but still it is a very quick, effective and easy way of suspecting or ruling out tracheal aspiration.
One quick method of suspecting tracheal aspiration or atleast ruling out tracheal aspiration is checking glucose concentration by regular bedside glucose meters. A glucose concentration of more than 20 mg/dl of bloodless tracheal aspirate doesn't confirm but atleast enhance the suspicion of tracheal aspiration.
Though literature is full of conflicting data for this method but still it is a very quick, effective and easy way of suspecting or ruling out tracheal aspiration.
Monday, January 17, 2011
Picture Diagnosis
Answer: chronic budd chiari syndrome and abdominal varices
Courtesy: doctorshangout.com here
Sunday, January 16, 2011
FDA alert: Severe liver injury associated with dronedarone (Multaq)
"The U.S. Food and Drug Administration (FDA) is alerting healthcare professionals and patients about cases of rare, but severe liver injury, including two cases of acute liver failure leading to liver transplant in patients treated with the heart medication dronedarone (Multaq)"
"The U.S. Food and Drug Administration (FDA) is alerting healthcare professionals and patients about cases of rare, but severe liver injury, including two cases of acute liver failure leading to liver transplant in patients treated with the heart medication dronedarone (Multaq)"
See full alert here
Saturday, January 15, 2011
Friday, January 14, 2011
Q: What is takotsubo cardiomyopathy?
Answer: Takotsubo cardiomyopathy, also known as broken-heart-syndrome, or simply stress cardiomyopathy, is a type of non-ischemic cardiomyopathy.
The hallmark of the disease is bulging out of the apex of the heart with preserved function of the base that earned the syndrome its name "tako tsubo", or octopus trap in Japan, where it was first described.The cause appears to involve high circulating levels of catecholamines. If individual survives their initial presentation, patient usually improves within 2 months. For unknown reason - Takotsubo cardiomyopathy is more commonly seen in post-menopausal women.
Answer: Takotsubo cardiomyopathy, also known as broken-heart-syndrome, or simply stress cardiomyopathy, is a type of non-ischemic cardiomyopathy.
The hallmark of the disease is bulging out of the apex of the heart with preserved function of the base that earned the syndrome its name "tako tsubo", or octopus trap in Japan, where it was first described.The cause appears to involve high circulating levels of catecholamines. If individual survives their initial presentation, patient usually improves within 2 months. For unknown reason - Takotsubo cardiomyopathy is more commonly seen in post-menopausal women.
Thursday, January 13, 2011
Wednesday, January 12, 2011
Q: Beside central diabetes, nephrogenic and gestational diabetes insipidus - what is Dipsogenic Diabetes Insipidus (DI)?
Answer: Dipsogenic DI is due to a defect or damage to the thirst mechanism, which is located in the hypothalamus. This defect results in an abnormal increase in thirst and fluid intake that suppresses ADH secretion and increases urine output.
Clinical significance: Desmopressin (or other drugs) should not be used to treat dipsogenic diabetes insipidus because they may decrease urine output but not thirst and fluid intake. This fluid "overload" can lead to water intoxication, leading to hyponatremia and so brain damage.
There is no effective treatment but some recommends small doses of DDAVP at bedtime to relieve nocturia.
Answer: Dipsogenic DI is due to a defect or damage to the thirst mechanism, which is located in the hypothalamus. This defect results in an abnormal increase in thirst and fluid intake that suppresses ADH secretion and increases urine output.
Clinical significance: Desmopressin (or other drugs) should not be used to treat dipsogenic diabetes insipidus because they may decrease urine output but not thirst and fluid intake. This fluid "overload" can lead to water intoxication, leading to hyponatremia and so brain damage.
There is no effective treatment but some recommends small doses of DDAVP at bedtime to relieve nocturia.
Tuesday, January 11, 2011
Q: 28 year old patient is admitted to ICU after traumatic brain injury. While evaluating films with radiologist he shows concerns of ischemia to pituitary gland, hypothalamus and surrounding structures. Which treatments you need to be worried if symptoms of Panhypopituitarism develops?
Answer: Pituitary hormones of clinical significance include
Answer: Pituitary hormones of clinical significance include
- adrenocorticotropic hormone (ACTH),
- follicle-stimulating hormone (FSH),
- luteinizing hormone (LH),
- growth hormone (GH),
- prolactin,
- thyroid-stimulating hormone (TSH), and
- antidiuretic hormone (ADH)
4 essential treatments to keep in mind:
- Desmopressin acetate (DDAVP) if Diabetes insipidus develops.
- Hydrocortisone: Should be initiated even before workup is initiated.
- Levo-thyroxine
- Reproductive hormones (Estrogen or Testosterone)
Growth hormone is not routinely replaced in adults.
Monday, January 10, 2011
Q: Describe 5 functions of angiotensin II ?
Answer: One of the functions of the kidney is to monitor blood pressure.
Kidney secretes renin.
Renin acts on angiotensinogen, splitting off a fragment called angiotensin I.
angiotensin I is cleaved by a angiotensin converting enzyme (ACE) — producing angiotensin II.
Angiotensin II
- constricts the walls of arterioles closing down capillary beds
- stimulates the proximal tubules in the kidney to reabsorb sodium ions
- stimulates the adrenal cortex to release aldosterone. (Aldosterone causes the kidneys to reclaim still more sodium and water).
- increases the strength of the heartbeat;
- stimulates the pituitary to release the vasopressin.
Sunday, January 9, 2011
Saturday, January 8, 2011
Q: 54 year old male developed life threatening GI bleeding after Fondaparinux (arixtra) administration post orthopedic surgery. FFP and pRBC is ordered and volume resuscitation started. What else can be done to counter effect of Fondaparinux (Arixtra)?
Answer: Recombinant Factor VIIa
Low-molecular-weight heparins are inhibitors of factor Xa, but have small therapeutic window and has the risk of bleeding. Fondaparinux has a long elimination half-life.
rFVIIa overcome the inhibition of thrombin generation and normalize the fondaparinux-induced prolongation of aPTT and PT. Sensitive thrombin-generation assays demonstrated the efficacy of rFVIIa in restoring impaired thrombin formation after fondaparinux administration. rFVIIa reverses not only the anticoagulant effect of fondaparinux but also the profibrinolytic effects of this agent, probably through activation of thrombin-activatable fibrinolysis inhibitor (TAFI).
Reference:
Ability of Recombinant Factor VIIa to Reverse the Anticoagulant Effect of the Pentasaccharide Fondaparinux in Healthy Volunteers - Circulation. 2002;106: 2550
Answer: Recombinant Factor VIIa
Low-molecular-weight heparins are inhibitors of factor Xa, but have small therapeutic window and has the risk of bleeding. Fondaparinux has a long elimination half-life.
rFVIIa overcome the inhibition of thrombin generation and normalize the fondaparinux-induced prolongation of aPTT and PT. Sensitive thrombin-generation assays demonstrated the efficacy of rFVIIa in restoring impaired thrombin formation after fondaparinux administration. rFVIIa reverses not only the anticoagulant effect of fondaparinux but also the profibrinolytic effects of this agent, probably through activation of thrombin-activatable fibrinolysis inhibitor (TAFI).
Reference:
Ability of Recombinant Factor VIIa to Reverse the Anticoagulant Effect of the Pentasaccharide Fondaparinux in Healthy Volunteers - Circulation. 2002;106: 2550
Friday, January 7, 2011
Q: Which is more sensitive bedside diagnostic in ruling out Pneumothorax - CXR or ultrasound (Choose one)?
Answer: Ultrasound
It is now pretty much establish that bedside ultrasound (can be easily learn and perform by intensivist) is more sensitive in detecting pneumothorax.
(see video in this regard in our videos section)
Reference:
Wilkerson RG, Stone MB (January 2010). "Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma". Acad. Emerg. Med. 17 (1): 11–17
Answer: Ultrasound
It is now pretty much establish that bedside ultrasound (can be easily learn and perform by intensivist) is more sensitive in detecting pneumothorax.
(see video in this regard in our videos section)
Reference:
Wilkerson RG, Stone MB (January 2010). "Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma". Acad. Emerg. Med. 17 (1): 11–17
Thursday, January 6, 2011
Wednesday, January 5, 2011
Q: 34 year old male with no medical access in past presented to ER with severe hypertension. On lab workup found to have hypokalemia and metabolic alkalosis. Your first diagnosis?
Hint: Triad of HTN, Hypokalemia and metabolic alkalosis
Answer: Primary hyperaldosteronism
Aldosterone hypersecretion acts on the cortical collecting duct to stimulate potassium secretion into the tubular fluid, enhancing renal potassium wasting.The metabolic alkalosis is due to increased renal hydrogen ion loss mediated by hypokalemia and aldosterone.
Tuesday, January 4, 2011
A short note on Dopexamine
Dopexamine is basically a β2-adrenergic receptor agonist. It is considered an inotropic agent. It can be use in heart failure for afterload reduction with positive inotropicity. Beside beta2-adrenergic stimulation it also stimulates peripheral dopamine (DA1 and DA2) receptors. Also it inhibits neuronal reuptake of noradrenaline (uptake-1).
Net effect is increase cardiac output through positive inotropism and reduce afterload through increased flow to renal and mesenteric beds. It improves gastric mucosal oxygenation.
Dose is infusion at 0.5 microgram per kg per minute increasing up to 6 micrograms per kg per minute. Central line infusion is recommended. As always with similar drugs patients receiving dopexamine should be monitored with EKG, hemodynamics, urine output etc. It may cause hypotension.
Dopexamine is not approved for use currently in the US or Canada.
Dopexamine is basically a β2-adrenergic receptor agonist. It is considered an inotropic agent. It can be use in heart failure for afterload reduction with positive inotropicity. Beside beta2-adrenergic stimulation it also stimulates peripheral dopamine (DA1 and DA2) receptors. Also it inhibits neuronal reuptake of noradrenaline (uptake-1).
Net effect is increase cardiac output through positive inotropism and reduce afterload through increased flow to renal and mesenteric beds. It improves gastric mucosal oxygenation.
Dose is infusion at 0.5 microgram per kg per minute increasing up to 6 micrograms per kg per minute. Central line infusion is recommended. As always with similar drugs patients receiving dopexamine should be monitored with EKG, hemodynamics, urine output etc. It may cause hypotension.
Dopexamine is not approved for use currently in the US or Canada.
Monday, January 3, 2011
Q: One advantage of Dronedarone (Multaq) over Amiodarone is removal of iodine moieties from its compound which decreases the side effects to thyroid, lung and nervous system. What other advantage it is said to have over Amiodarone?
Answer: It has much shorter half life.
Dronedarone is less lipophilic and so has an elimination half-life of only 24 hours in contrast to amiodarone which has half life extended over several weeks.
Answer: It has much shorter half life.
Dronedarone is less lipophilic and so has an elimination half-life of only 24 hours in contrast to amiodarone which has half life extended over several weeks.
Sunday, January 2, 2011
Q: Can Amiodarone be given to a patient with documented allergy to shellfish or contrast media due to its iodine content?
Answer: Yes - usually its safe
Documented allergies to contrast media or shellfish should not imply that a patient is allergic to iodine. Reactions to contrast media are due to the high osmolar or ionic content of the dye. The primary allergen in shellfish is tropomyosin. No known association exists between amiodarone and reactions to contrast media or shellfish. Unless until true allergy exist specifically for iodine, Amiodarone is usually a very safe medicine from this perspective.
Answer: Yes - usually its safe
Documented allergies to contrast media or shellfish should not imply that a patient is allergic to iodine. Reactions to contrast media are due to the high osmolar or ionic content of the dye. The primary allergen in shellfish is tropomyosin. No known association exists between amiodarone and reactions to contrast media or shellfish. Unless until true allergy exist specifically for iodine, Amiodarone is usually a very safe medicine from this perspective.
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