Saturday, April 30, 2011
Declining LDH level is a pretty good indicator that plasma exchange is working to treat TTP.
Friday, April 29, 2011
Ans: Fat embolism syndrome usually occur 1-3 days after a traumatic injury and are predominantly
- pulmonary - shortness of breath, hypoxemia,
- neurological - agitation, delirium, or coma,
- dermatological - petechial rash, and
- haematological - anaemia, low platelets
Treatment is supportive.
Thursday, April 28, 2011
Diagnosis: Botulism (110 cases in US per year with 3 percent being wound Botulism)
Differential diagnosis: Mysthenia Gravis, Lambert-Eaton syndrome, Guillain-Barre’s syndrome, poliolmyelitis, Ticks paralysis, heavy metal intoxication.
Botulism has an acute onset with bilateral cranial neuropathies and symmetric descending weakness. Key feature include:
•Patient is afebrile
•Symmetric neurological deficit
•Patient is responsive
•Normal or slow heart rate and normal blood pressure
•No sensory deficit
•Equine serum botulism antitoxin
•Penicillin G intravenously 3 grams every 4 hours
Wednesday, April 27, 2011
describes which toxicity?
Answer: Anticholinergic toxicity. Symptoms include
- Dry skin,
- Urinary retention
Tuesday, April 26, 2011
PWP should be measured as
- mean of 'A' wave
- at end expiration
- after QRS complex of EKG
It is recommended to read wedge pressure from paper print out instead of directly from monitor
It is recommended to read wedge pressure from paper print out instead of directly from monitor
Monday, April 25, 2011
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.
Sunday, April 24, 2011
Answer:The doses of glucagon required to reverse severe beta-blockade are 50 micrograms/kg iv loading dose, followed by a continuous infusion of 1-15 mg/h, titrated to patient response.
Glucagon has shown similar benefit but to lesser extent in Calcium-channel blockers overdose.
Saturday, April 23, 2011
Answer: LAD (left anterior descending coronary artery) aneurysm
Also notice stenosis of distal left main coronary artery along with large proximal LAD aneurysm.
Coronary aneurysms may be from trauma during cardiac catheterization, but it is the hallmark of Kawasaki disease.
Friday, April 22, 2011
A serum-ascites albumin gradient (SAAG) is a useful test for differential diagnosis of Ascites. Both should be drawn/measured at same time.
Thursday, April 21, 2011
Answer: Follow serial QT duration
Surprisingly, Overdose with amiodarone is usually benign as it is very poorly and variably absorbed. But all such patients should be admitted to ICU/CCU for close observation and serial EKGs.
On EKG, Amiodarone leads to a prolonged QT interval due to its blocking of repolarising of. potassium channel. The QT duration is the best indicator of the extent of potassium channel blockade.
Wednesday, April 20, 2011
Interesting study published this month (May 2011) in CCM Journal regarding selective digestive tract decontamination aims to eradicate Gram-negative bacteria in both the intestinal tract and respiratory tract. Patients selected were with ICU stay of more than 48 hrs that received selective digestive tract decontamination (n = 2,667), selective oropharyngeal decontamination (n = 2,166) or standard care (n = 1,945).
Results showed that respiratory tract decolonization was associated with a 33% and intestinal tract decolonization was associated with a 45% reduction in the occurrence of intensive care unit-acquired Gram-negative bacteremia.
The role of intestinal colonization with Gram-negative bacteria as a source for intensive care unit-acquired bacteremia - Critical Care Medicine: May 2011 - Volume 39 - Issue 5 - pp 961-966
Tuesday, April 19, 2011
Monday, April 18, 2011
Answer:For massive right-sided pulmonary bleeding, the left mainstem bronchus is intubated over the bronchoscope. Unilateral intubation of the right lung with massive left-sided bleeds is not recommended due to the risk of right upper lobe occlusion. Alternative in this case is to use a double lumen endotracheal tube to isolate the unaffected lung.
Sunday, April 17, 2011
"When my brother went into the hospital with pneumonia, he quickly contracted four other infections in the intensive care unit.
Anguished, I asked a young doctor why this was happening. Wearing a white lab coat and blue tie, he did a show-and-tell. He leaned over Michael and let his tie brush my sedated brother’s hospital gown.
“It could be anything,” he said. “It could be my tie spreading germs.”
I was dumbfounded. “Then why do you wear a tie?” I asked. He shrugged and left for rounds.
Read full article by Maureen Dowd in NYThere
Saturday, April 16, 2011
Severe hyponatremia associated with intake of large quantities of beer or after episode of binge beer drinking is called beer potomania. Patients usually present with mental status change deteriorating into seizure or coma. Pathophysiology Clinical significance:
Pathophysiology:Hypoosmolality of the beer associated with poor nutrition leads to the inability to excrete sufficient amounts of free water.
Clinical significance:This hyponatremia doesn't respond well to restriction of free water but treatment with isotonic saline results in the rapid clearance of the accumulated excess free water and clinical improvement.
Friday, April 15, 2011
Answer: Sildenafil not only decreases pulmonary pressures but also prevents rebound pulmonary vasoconstriction on withdrawal of inhaled NO.
Mehta S. Sildenafil for pulmonary arterial hypertension: exciting, but protection required. Chest. 2003 Apr; 123(4): 989-92.
Thursday, April 14, 2011
Prograf (FK 506,Tacrolimus) is a commonly used medicine in transplant patients and its level should be monitored closely. Dosage should be adjusted based on the trough levels of medication. Normal trough level is 5-15 ng/ml.
Prograf toxicity may cause blurred vision, liver and renal failure, tremors, hyperkalemia, hypomagnesemia, and neurological problems such as seizure, encephalopathy, cerebral edema, confusion etc.
Wednesday, April 13, 2011
Q: What is Bickerstaff's brainstem encephalitis (BBE)? Answer
Answer: Bickerstaff's brainstem encephalitis (BBE), is a variant of Guillain–Barré syndrome. It is characterized by acute onset of
- disturbance of consciousness,
- hyperreflexia or Babinski's sign
The course of the disease can be monophasic or remitting-relapsing but despite severe initial presentation usually it has a good prognosis. MRI plays a critical role in the diagnosis of BBE, characterized by large, irregular hyperintense lesions located mainly in the brainstem, especially in the pons, midbrain and medulla.
Tuesday, April 12, 2011
Emphysematous pyelonephritis is a necrotizing acute nephritis with extension of the infection through the renal capsule. This leads to the presence of gas within the kidney and in the perinephric space.
The mortality rate is 60% - 80% despite medical treatment and usually require surgical intervention with nephrectomy.
Monday, April 11, 2011
Q: Hypotension secondary to Milrinone therapy can be managed more efficiently with which pressor? A) Norepinehrine B) Dopamine C) Vasopressin D) Phenylephrine E) Epinephrine Answer: Vasopressin
Certainly any pressor can be use for hypotension but literature point towards vasopressin as better choice of pressor in milrinone induced hypotension. Low-dose vasopressin decreased the PVR/SVR ratio that was increased by milrinone. Considering the importance of maintaining systemic perfusion pressure as well as reducing right heart afterload, milrinone–vasopressin may provide better hemodynamics than milrinone–norephinephrine during the management of right heart failure.
Comparative hemodynamic effects of vasopressin and norepinephrine after milrinone-induced hypotension in off-pump coronary artery bypass surgical patients - Eur J Cardiothorac Surg 2006;29:952-956
Sunday, April 10, 2011
Case: 47 year old male of Indian sub-continent origin admitted to ICU with status epilepticus. Patient has recently been started on TB prophylaxis medicine at his new work place. What is your probable diagnosis and what would be the treatment?
Answer: Isoniazid (INH) induced seizures. Isoniazid (INH) induced seizures is unique in the sense that it is usually refractory to standard anticonvulsant therapy. Even dose as low as as 1.5 g can be neurologically toxic. INH induced seizure requires administration of a specific antidote, pyridoxine (B-6), with dose of 5 gram in IV form. Dose can be repeated 2 to 3 times if needed.
Isoniazid (INH) induced seizures is unique in the sense that it is usually refractory to standard anticonvulsant therapy. Even dose as low as as 1.5 g can be neurologically toxic.
INH induced seizure requires administration of a specific antidote, pyridoxine (B-6), with dose of 5 gram in IV form. Dose can be repeated 2 to 3 times if needed.
Saturday, April 9, 2011
Answer:Atropine test is a simple pharmacological test based on the absence of cranial parasympathetic nervous influence on the heart in brain dead patients and may be a useful adjunct to testing brain stem function. A tachycardic response would demonstrate an intact cranial parasympathetic outflow. 2-3 mg of Atropine IV is then given. If there is less than 10 % or no increase in heart rate, this supports the diagnosis of brain death. Additional confirmatory tests are however required.
Friday, April 8, 2011
A simple technique for anchoring chest tubes - M.A. Rashid, T. Wikström, P. Örtenwall, Eur Respir J 1998; 12: 958–959
Thursday, April 7, 2011
Answer: Bilateral Pneumothoraces Bilateral pneumothoraces can be very deceiving as there is no deviation of trachea, and percussion and breath sounds seems equal on both sides. Clinically these patients are usually haemodynamically compromised and on CXR you may see the characteristic 'disappearing heart' with bilateral tension pneumothoraces.
Wednesday, April 6, 2011
Answer:Administer Magnesium before ibutalide use
The risk of developing torsade de pointes with ibutilide is about 4% but it can reduced with intravenous infusion of high-dose magnesium sulfate and having potassium level around 4.5 range.
Reference: Patsilinakos S, Christou A, Kafkas N, et al. Effect of high doses of magnesium on converting ibutilide to a safe and more effective agent. Am J Cardiol 2010; 106: 673–6
Tuesday, April 5, 2011
Answer:Lorazepam and diazepam both have been used as a first line drugs in the management of Status Epilepticus. Though diazepam acts slightly faster than lorazepam its effective duration of action may be only 5-10 min - and may require repeated doses or quick followup with administration of phenytoin (or fosphenytoin). On the other hand once effective dose(s) of lorazepam is given, the effective duration of action of lorazepam is 8-10 hours, and so is more recommended for initial treatment of status epilepticus.
Monday, April 4, 2011
Amniotic fluid embolism (AFE) is a misnomer as clinical picture is more or less like acute collapse from pulmonary embolism but in fact it is an allergic type reaction. Amniotic fluid embolism (AFE) is a rare obstetric emergency in which amniotic fluid, fetal cells, hair, or other debris enters the mother's blood stream and triggers an allergic reaction - which results in cardiorespiratory collapse. Another hallmark of the disease is severe coagulopathy. Diagnosis: Treatment:
Diagnosis:In a patient who is suspected of having AFE, a sample should be obtained by aspiration of the distal port of a pulmonary artery catheter. If sample contains fetal squamous cells it is highly suggestive of AFE syndrome - but does not completely rule in or rule out other causes too.
Treatment:Immediate delivery of baby. Support coagulopathy and hemodynamics as per standard.
Sunday, April 3, 2011
Answer: Hamman's syndrome is a clinical condition and frequently requires ICU admission for observation. It is a spontaneous pneumomediastinum with subcutaneous emphysema. It occurs mostly in young females peripartum or postpartum. It is named after the physician (Louis Hamman 1877–1946), who described it.
Hamman's syndrome usually occurs in the second stage of labor but can be delayed to the postpartum phase. An association with prolonged labor has been proposed (increase intrathoracic pressure) with rupture of alveoli.
Treatment is supportive and course is usually benign.
Dudley DK, Patten DE. Intrapartum pneumomediastinum associated with subcutaneous emphysema. CMAJ 1988;139:641-2
Saturday, April 2, 2011
Cardizem (Diltiazem) is frequently used in the treatment of anal fissures - either via oral route or can be applied topically!
It has a very good short term success rates and provide temporary relief till surgical intervention is done, if required. Local application of it relaxes the sphincter muscle, and allows the healing to proceed.
Friday, April 1, 2011
Answer:There are 2 synergistic components to this pathophysiology.
1. Bile Stasis: Absence of oral/enteral feeding results in a decrease or absence of cholecystokinin-induced gallbladder contraction.
2. Increase Bile Viscosity: Increased bile viscosity due to fever and dehydration causes acalculous cholycystitis.