Lines, tubes and drains
Tox & Withdrawal
Lytes gone wild!
Periopertive puzzles..
Hospital horror gallery!!
100
Is this NG tube in acceptable position to start feeds?
Yes!!!
tip clearly visible below the left hemidiaphragm in the stomach!!
100
What CIWA score threshold typically prompts scheduled or as needed benzodiazepine dosing for alcohol withdrawal
CIWA score > 8-10
100
what is the recommended rate of sodium correction in 24 hours for chronic hyponatremia and why?
no more than 8 in 24 hours! to avoid osmotic demyelination syndrome
100
What is the most common cause of fever in the first 24-48 hours after surgery??
Atelectasis (though this is somewhat debated) encourage incentive spirometry and ambulation.
100
67 y/o F with painful vesicular rash involving forehead and tip of the nose. what is the best next step?
urgent opthalmology consult and immediate systemic antiviral therapy!!! patient has herpes zoster opthtalmicus. (hutchinson sign) > rash at the tip of the nose
200
A femoral central line placed 3 days ago now has a pulsatile hematoma expanding at the insertion site. Single most likely cause?
Arterial puncture/pseudoaneurysm — the femoral artery runs immediately adjacent to the vein, and a pulsatile expanding mass at the site is pseudoaneurysm until proven otherwise.
What to do next?????
200
A patient on naloxone for opiod overdose starts vomiting and becomes agitated shortly after reversal, what is going on???
Precipitated opiod withdrawal
Naloxone reversed the opiod too abruptly, manage supportively rather than redosing more naloxone.
withdrawal generally improves as naloxone wears off (30-90 minutes)
200
A patient with hyponatremia (Na 118) is started on a slow appropriate correction, but their sodium jumps 6 in the first 6 hours alone despite only receiving maintenance fluids. urinary output has also markedly increased. whats happening and what should you do??
Rapid aquaresis from spontaneous resolution of the SIADH like state (or from stopping the offending trigger) the kidneys are now excreting free water rapidly on their own, independent of what being infused, this requires proactive intervention (D5W or desmopressin clamp) to prevent overcorrection.
200
74 yo F is POD2 from emergent bowel resection. overnight she became acutely confused, pulling her lines, then an hour later was somnolent and difficult to arouse then became agitated again. VS and labs are unremarkable. family says she was completely at baseline before surgery. whats the diagnosis and what the ingle biggest management pitfall to avoid?
post op delirium!!! the biggest pitfall is reflexively reaching for benzos or heavy sedation to manage the agitation which worsens delirium instead prioritize reorientation, correcting sensory deficits, sleep wake cycle support.
200
62 ESRD patient presents with excruciating penile pain and black necrotic lesion. the lesion appears infected but cultures are negative. what is the most likely diagnosis?
penile calciphylaxis!!
300
A chest tube placed for a large pneumothorax shows continuous bubbling in the water seal chamber that never stops, even with clamping trials. Where is the air leak most likely coming from — the pleural space or the tubing/system?
The system itself (tubing connection or dressing seal) — a persistent air leak that doesn't change with clamping at the chest wall points to the tube/dressing, not the lung.
300
What is the classic triad concerning for Wernicke encephalopathy in an alcoholic patient AND what do you give before glucose?
confusion, ataxia, opthalmoplegia. give thiamine before or with glucose to avoid precipitating/worsening wenickes.
300
A hyperkalemic patient K 6.8 gets calcium gluconate, insulin/glucose adn albuterol and repeat K 1 hour later is 5.2. 4 hours later K is back to 6.9 with no new K intake. what is the most likely explanation?
Patient only got temporizing measures that shifts K inside the cell and wears off in hours! without an agent that actually removes K (patiromer, sodium zirconium, dialysis) or correction of the underlying cause, potassium rebounds as the shift effects fades.
300
A patient with atrial fibrillation on eliquis is scheduled for an elective surgery. Should this patient receive heparin bridging after the DOAC is stopped???
NO!! DOACs generally do not require bridging because they have rapid onset and short half like so bridging increases bleeding risk w/o reducing thromboembolic events. WHO TO ALWAYS BRIDGE??
Mechanical mitral valve, stroke tia in the past 3 months, CTE within the past 3 months, selected patient with very high risk of atrial fibrillation.
300
54 y/o M with DM presents with severe out of proportion leg pain, 6 hour later the skin develops hemorrhagic bullae and violaceous discoloration. what is the diagnosis?
necrotizing fasciitis!!!!
Call surgery ASAP!!
400
A PICC line placed for a right basilic vein access now shows arm swelling and the patient reports arm heaviness. Single best next test?
Upper extremity ultrasound — to evaluate for PICC-associated deep vein thrombosis, the leading complication causing unilateral arm swelling with a PICC in place.
400
A patient on your alcohol withdrawal protoclol is getting esclating CIWA driven benzo doses but remains tremolous and tachycardic with no sedation at all.
What single lab abnormality commonly drives this apparent benzo resistance???
HYPOMAGNESEMIA, mg is a cofactor for GABA receptor function, and uncorrected hypomg blunts the effect of benzos, mimicking treatment resistance.
400
68 yo M with CKD with stage 5 not o n HD comes with severe symptomatic hypercalcemia, what is the preferred antiresorptive therapy???
Denosumab!! or dialysis if hypercalcemia is refractory or life threatening.
why not biphosphonates?
400
How do you risk-stratify a patient's cardiac risk before non-cardiac surgery using functional capacity?
Assess METs, ability to climb 2 flights of stairs w/o symptoms suggests adequate functional reserve and generally doesn't need further cardiac testing.
if the patient climbs stair w/o problem he is good for surgery!
400
64 y/o f with pmh poorly controlled DM presents with septic shock, her ct scan is bellow,. what is the dx???
emphysematous pyelonephritis!!!!!!!!!!
500
A patient with a chronic indwelling foley for 3 weeks develops fever and hypotension. Urine is clear and urinalysis is unremarkable. Should you still treat this as catheter-associated UTI?
No — a clear UA with a negative or bland urinalysis argues against CAUTI as the source; look elsewhere for the infection source rather than anchoring on the catheter.
500
A patient is brought in after a suspected polysubstance ingestion. they have miosis, bradycardia and hypothermia, but are also profoundly hypoglycemia and diaphoretic and naloxone doesnt fully reverse their mental status.
What co-ingestant should you specifically test for that naloxone wont touch?
Sulfonylurea or insulin!! the hypoglyceia here isnt from opiod, a sulfonylurea overdose can mimic an opiod toxidrome via sedations but requires dextrose/octeotride. no more naloxone to correct the underlying hypoglycemic driver.
500
35 y/o asian M presents with recurrent episodes of flaccid paralysis after eating pizza late at night. He has tachycardia and a fine tremor
K 1.9, TSH undetectable and Free t4 is elevated.
what is the underlying diagnosis?
thyrotoxic periodic paralysis!
most common in Asian and Hispanic men. the hypokalemia results from shift of K into cells due to increase NA/K atpase activity stimulated by thyroid hormone and cathecolamines.
500
76 y/o M taking xarelto for afib presents with perforated bowel and requires emergent surgery within the hour, what is the best strategy to reverse his anticoagulation?
4 factor prothombin complex concentrate! takes 20 minutes to give! although specific antidote is andexanet alfa it cost 20K and is a two step infusion, 15-30 bolus then 120 minutes continuous infusion. use it in life threatening bleeding rather than urgent operative reversal.
500
this neutropenic patient presents with fevers and a painless necrotic ulcer with black eschar surrounded by erythema. which organism is classically associated with this lesion?
Pseudonoma aeruginosa!!!
patient has ecthyma gangrenosum!!! immediately start antipseudomonal therapy! the diagnosis of clinical, dont wait for cultureS!!