Our current approach to allergy is primarily patient-based. This focuses on the patient’s prior history of reaction: how severe was it, when was it, how certain are we that it was truly allergic? This strategy has been proven to be inaccurate. For example, ~90% of patients who report a penicillin allergy are not allergic when skin-tested.
PulmCrit- Who needs empiric coverage for HSV encephalitis?
There is significant practice variation regarding whether to give empiric acyclovir while awaiting PCR results. The goal of this post is to search for an evidence-based approach to this issue.
PulmCrit: Algorithm for diagnosing ICP elevation with ocular sonography
Introduction with a clinical question A young woman is transferred to the ICU from an outside hospital due to severely depressed mental status, thought due to intoxication. You evaluate her intracranial pressure using ocular ultrasonography. Evaluation of the optic disc diameter in both eyes and in both orientations yields four measurements: 5.5 mm and 6.0 […]
PulmCrit: Large-bore suction for intubation: strategies & devices
The ideal suction tool for intubations is debatable, but it seems clear that the Yankauer is a poor choice. Persistent use of the Yankauer suction catheter for airway management represents a profession-wide failure in our ability to manage large-volume regurgitation.
PulmCrit: The ketamine-tolerant patient
The ketamine-tolerant patient presents a quandary to clinicians who aren’t familiar with this phenomenon. The first time I encountered this, I was baffled and aborted the procedure after giving 200 mg ketamine. Eventually I realized that the drug isn’t “failing” to work, but rather we are failing to administer a sufficiently high dose.
Service update: Bleeding Edge Series
Effective, rapid peer review allows for the creation of a new series of posts. These posts will cover material which isn’t supported by much evidence nor experience. In the past, I wouldn’t have felt comfortable posting this material to the blog.
PulmCrit- Brain death, mimics, and flow scans
As with many uncommon situations that are unique to critical illness, we cannot always rely on specialist consultation. Critical care practitioners must develop a firm grasp of this diagnosis. This post will explore some diagnostic conundrums in brain death diagnosis. The radionuclide flow scan is emphasized because it is the most commonly used tool to sort out difficult cases.
PulmCrit- Toxicology dogmalysis: the osmolal gap
I’ve been checking the serum osmolal gap on patients with toxic ingestion for years. However, the osmolal gap has yet to crack a case for me. There have been lots of patients with elevated osmolal gaps due to uremia or ketoacidosis. Meanwhile, the cases of ethylene glycol or methanol intoxication which I have encountered have […]
PulmCrit – Central venous oxygen saturation: signal or noise?
Recently a few cases at Genius General have arisen where cvO2% was misleading. Specifically, the cvO2% was elevated despite cardiogenic or hemorrhagic shock. This post will attempt to explore why this might occur.
PulmCrit- The gag reflex shouldn’t be tested in living patients
As a medical student I rotated through an elite hospital where it was believed that every patient admitted to the medicine service needed a rectal exam. The rationale was to avoid ever missing a case of rectal or prostate cancer. Eventually, the utility of digital rectal examination as a cancer-screening tool was debunked. Thankfully, this practice has fallen out of favor.
PulmCrit – Mythbusting sensitivity and specificity
Likelihood ratios may be more useful clinically, but sensitivity and specificity are more widely reported. Therefore, it is useful to gain a general understanding of how sensitivity and specificity translate into likelihood ratios.
PulmCrit- Reengineering the analgesic ladder for critically ill patients
We all want to alleviate pain and suffering. Most critically ill patients are treated with opioids for this reason. Unfortunately, opioids have numerous side-effects including delirium, constipation, vomiting, and delayed extubation. Opioid infusions may eventually lead to withdrawal, causing pain, nausea, and depression. This post explores the optimal use of systemic medications to control pain while minimizing complications.
PulmCrit- Liberating the patient with no cuff leak
A new joint practice guideline by the ATS and ACCP addresses how to approach cuff leaks. This guideline recommends a clever compromise between these extremes, which is the basis of the algorithm below. This provides a streamlined, evidence-based pathway to extubate patients without a cuff leak.
PulmCrit- Resuscitationist’s guide to status epilepticus
In 2014 I wrote a post suggesting an aggressive, streamlined approach to status epilepticus involving early intubation. The fundamentals of that post remain valid. However, much has changed over the last few years. This post aims to refresh and extend the prior post. It will also serve as a reference to explain my algorithm for […]
PulmCrit- Rocketamine vs. keturonium for rapid sequence intubation
Background: Devil in the details Airway management is a detail-oriented sport. Minor nuances of patient positioning can be essential. Or gentle laryngeal manipulation. Apneic oxygenation can improve first-pass success. Placing the pulse oximeter on the same arm as the blood pressure cuff can cause real headache. Failure to recognize and remove dentures is an enormous […]
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