Mnemonic for NMS

Neuroleptic malignant syndrome (NMS) is a life- threatening disorder most often caused by neuroleptic or antipsychotic drugs.

Mnemonic for NMS: FALTER

F – Fever
A – Autonomic instability (Vitals)
L – Leukocytosis
T – Tremor
E – Elevated enzymes (elevated CPK)
R – Rigidity of muscles

The Challenge of the ICU

In one recent article 4 keys have been identified for success against challenges of the ICU

Success Key No.1: Overcoming sepsis

Success Key No.2: Rapid response team

Success Key 3: Reducing CLABSIs (central line–associated bloodstream infections).

Success Key No. 4: Improving care with intensivists

Read full article here

Q: Deficiency of which vitamin may cause lactic acidosis?

Answer: Thiamine (Vitamin B1)

Clinically it may become significant in patients who have prolong NPO status or have TPN without essential vitamins in it. It should also be considered in patients who alcohol abuse and poor intake.

Severe lactic acidosis and thiamine deficiency during total parenteral nutrition--case report. Hepatogastroenterology. 2004 Jan-Feb;51(55):253-5.

Schonfeld's Criteria for Fat Embolism Syndrome

Schonfeld's Criteria propoose seven clinical features to diagnose fat embolism syndrome. A score of more than 5 is required for a positive diagnosis.

Q; 52 year old female with history of hypertension - but controlled with Lisinopril developed UTI (urinary tract infection). What should be your worry to treat her with Bactrim (TMP-SMX)?



Answer: Hyperkalemia

The mechanism of Bactrim induced hyperkalemia is via Trimethoprim inhibition of the sodium channel located on the luminal surface of the principal cells. This decreases sodium reabsorption and the electro negativity in the lumen thus decreases the driving force for the secretion of potassium through an apically located potassium channel on the same principal cells.

This side effect is most common in HIV infected patients who are treated with high doses of TMP-SMX. However hyperkalemia can occur with lower doses in patients with preexisting renal dysfunction or in those taking medications such as angiotensin-converting enzyme inhibitors or potassium-sparing diuretics. It may exacerbate hyperkalemic effect to potentially dangerous levels.

Q: 32 year old male with sickle cell disease presented to ER with severe episode of priapism. What should be considered?


Answer: For priapism in sickle cell disease, early exchange transfusion is indicated, meanwhile pain can be controlled with epidural analgesia. Exchange transfusions may be required to increase hemoglobin concentration to higher than 10% and decrease hemoglobin S to less than 30%. Before any intervention urology consult should be obtiained for possible use of terbutaline and pseudoephedrine. Some studies suggest that the use of terbutaline orally, at a dose of 5-10 mg, followed by another 5-10 mg 15 minutes later, if required, produces resolution in about one third of patients. Oral pseudoephedrine, 60-120 mg orally has also been suggested as a potential therapy due to its alpha-agonist effect. The exact efficacy of this medication orally is unknown.

Q; Nimodipine has strong 'black box' warning against IV administration but still there are reports of IV administration of Nimodipine 'by error'. How?


Answer: Intravenous nimodipine can result in death, cardiac arrest, due to acute fall in blood pressure.

When PO administration is not feasible it is given via nasogastric tube. The recommended way is to make a hole in both ends of the capsule with an 18 gauge needle, and the contents of the capsule extracted into a syringe. This may be the reason of 'by error' administration of Nimodipine via IV route.

FDA advise that the syringe be labeled "Not for IV Use." The needle should be removed from the syringe and the contents should then be emptied into the patient's in situ nasogastric tube and washed down the tube with 30 mL of normal saline (0.9%).



Source: FDA (here)

Q; Why GI decontamination has limited role in lithium toxicity?


Answer: Lithium does not bind to charcoal.

Whole-bowel irrigation with polyethylene glycol is said to have partial effectiveness.

Hunter's criteria for SSRI toxicity

Ice test in Myasthenia Gravis

Most of the Myasthenia patients along with other symptoms of weakness usually exhibits ptosis. While at bedside place an ice cube over eye lids for 2 minutes. Cooling improves neuromuscular transmission. Resolution of ptosis with cooling is a positive test for Myasthenia Gravis and reported upto 80% reliable to diagnose ocular myasthenia.

Q: What is MELAS Syndrome?


Answer: It stands for

• Mitochondrial myopathy,


• Encephalopathy,


• Lactic Acidosis, and


• stroke like episodes

It occurs due to defect in mitochondrial genome. Important diagnostic feature - it is inherited purely from the maternal parent though can manifest in either gender.

Early symptoms include muscle, headaches, vomiting, and seizures and lately stroke-like episodes.

"MELAS episode" or attack appears as temporary hemiparesis, altered consciousness, vision abnormalities, seizures and severe headaches like migraines. Most people with MELAS buildup of lactic acid due to mitochondrial error.

There is no treatment known but it is described that Riboflavin (vitamin B2) may help.

Q: Name the organism after knowing following 5 tips

1. Usually happen in warm-weather months

2. Assosicated with eating Raw oyster

3. Common in immunocpromised patients

4. Also common in patients with liver insufficiency secondary to alcohol or hepatitis

5. One of the clinical sign is cutaneous bullae?



Answer: Vibrio vulnificus

Vibrio vulnificus is a Gram-negative, motile, curved, rod-shaped bacteria of the Vibrio Genus. It can cause rapidly expanding cellulitis and septicemia. It is present in marine environments and causes an infection often after eating seafood, especially raw or undercooked oysters; the bacteria can also enter the body through open wounds when swimming in infected waters. Symptoms include vomiting, diarrhea, abdominal pain, and a blistering dermatitis. It is common in immunocpromised patients and in patients with liver insufficiency.

Q: One most important thing to know about Candida Glabrata?


Answer: Diflucan (fluconazole) does not cover it.

Candida Glabrata once thought to be rare in hospital patients is now increasingly more common. C. glabrata possesses an 'evolved resistance' to the azole drugs (fluconazole and ketoconazole). Drug of choices are amphotericin B and caspofungin.

Mnemonic for Ranson criteria of Acute Pancreatitis

Ranson criteria is a clinical prediction rule severity of acute pancreatitis.

At admission: "GA LAW"

Glucose; more than 200 mg/dL
AST: more than 250 IU/L

LDH: more than 350 IU/L
Age: more than 55 years
WBC: more than 16000 cells/mm3


At 48 hours: "C Hobbs"

Calcium: less than 8.0 mg/dL

Hematocrit fall more than 10%

Oxygen: PO2 less than60 mmHg
BUN increased by 1.5 or more mg/dL after IV fluid hydration
Base deficit: more than 4 mEq/L
Sequestration of fluids: more than 6 L


Score 0 to 2 : 2% mortality
Score 3 to 4 : 15% mortality
Score 5 to 6 : 40% mortality
Score 7 to 8 : 100% mortality

Q: 34 year old female with no significant past medical history is admitted with urosepsis. EKG was ordered as 'routine'. What is your diagnosis?

Answer: Wolff-Parkinson-White syndrome

Wolff–Parkinson–White syndrome (WPW) is a syndrome of pre-excitation of ventricles of the heart due to an accessory pathway called bundle of Kent. WPW syndrome gets diagnosed in asymptomatic people on EKG via delta wave, which is a slurred upstroke in the QRS complex associated with a short PR interval. (see above in EKG.

Q: What is the treatment of hypermagnesemia?


Ans: IV calcium

IV calcium should be coupled with IVF combined with lasix. If clinical signs become unstable dialysis is the ultimate answer.