EMCrit Project http://emcrit.org Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Mon, 10 Dec 2018 19:24:52 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.8 http://emcrit.org/feed/podcast/ Help me fill in the blanks of the practice of ED Critical Care. In this podcast, we discuss all things related to the crashing, critically ill patient in the Emergency Department. Find the show notes at emcrit.org. Scott D. Weingart, MD clean episodic Scott D. Weingart, MD spambin55@gmail.com spambin55@gmail.com (Scott D. Weingart, MD) 2009- Online Medical Education on Emergency Department (ED) Critical Care, Trauma, & Resuscitation EMCrit Project http://emcrit.org/wp-content/uploads/powerpress/3000x3000-emcrit.jpg http://emcrit.org/category/pulmcrit/ IBCC chapter & cast: Post-cardiac arrest management http://emcrit.org/pulmcrit/post-arrest/ http://emcrit.org/pulmcrit/post-arrest/#comments Wed, 05 Dec 2018 14:35:50 +0000 http://emcrit.org/?p=455859 Post-cardiac arrest management has undergone substantial revisions within the past several years, particularly with regards to temperature management.  This remains an area of active controversy and investigation, with the TTM-2 trial currently underway.  Although equipoise still exists, this chapter describes a streamlined 36C approach which is based on evidence, guidelines, and experience with various strategies. […]

EMCrit Project by Josh Farkas.

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PulmCrit- Alpha-2 agonists: clonidine, guanfacine, lofexidine, and KetaDex http://emcrit.org/pulmcrit/ketadex/ http://emcrit.org/pulmcrit/ketadex/#comments Mon, 03 Dec 2018 13:50:06 +0000 http://emcrit.org/?p=455808 Dexmedetomidine is an intravenous alpha-2 agonist used as a sedative infusion.  It has some uniquely useful properties, particularly that it doesn’t suppress respiration (allowing it to be safely used in non-intubated patients).  The main drawbacks of dexmedetomidine are logistic:  it is expensive and can be administered only as an IV infusion within an ED or ICU.  Oral clonidine offers some similar benefits compared to dexmedetomidine, without these logistic constraints.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Meningitis and encephalitis http://emcrit.org/pulmcrit/meningitis-2/ http://emcrit.org/pulmcrit/meningitis-2/#comments Wed, 28 Nov 2018 11:44:48 +0000 http://emcrit.org/?p=455732 Severe CNS infections are a bit of an orphan disease in critical care.  Unlike more common neurologic disorders (e.g. stroke), CNS infections are too rare to recruit lots of patients into RCTs.  Consequently, conventional treatment of these disorders lags decades behind other neurologic disorders (e.g. in terms of optimizing cerebral perfusion pressure).  Principles of neurocritical […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Torsades de Pointes http://emcrit.org/pulmcrit/tdp/ http://emcrit.org/pulmcrit/tdp/#comments Wed, 21 Nov 2018 13:51:08 +0000 http://emcrit.org/?p=455493 Torsades de pointes is an uncommon cause of cardiac arrest.  It is generally quite treatable, but if treated inadequately it will often recur (in some cases leading to repeated salvos of ventricular tachycardia, one form an electrical storm).  A structured approach incorporating a pre-emptive protocoled magnesium infusion is generally quite effective. The IBCC chapter is […]

EMCrit Project by Josh Farkas.

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IBCC: Guide to supportive care in critical illness http://emcrit.org/pulmcrit/guide/ http://emcrit.org/pulmcrit/guide/#comments Mon, 19 Nov 2018 15:10:35 +0000 http://emcrit.org/?p=455440 This chapter gives an overview of how to provide high-quality supportive care to the sickest patients.  It summarizes about a dozen chapters within the IBCC.  This is intended as a quick guide for folks who don't work full-time in an ICU (e.g. residents rotating through the unit).  

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Hyperkalemia http://emcrit.org/pulmcrit/hyperk/ http://emcrit.org/pulmcrit/hyperk/#comments Wed, 14 Nov 2018 11:09:04 +0000 http://emcrit.org/?p=455366 Hyperkalemia is bread and butter critical care medicine.  However, the therapeutic approach has changed substantially within the past 5 years. Myths about kayexalate and normal saline have been exposed, allowing more effective therapies to take their place.  

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Delirium http://emcrit.org/pulmcrit/delirium/ http://emcrit.org/pulmcrit/delirium/#comments Wed, 07 Nov 2018 13:50:19 +0000 http://emcrit.org/?p=455234 Delirium occurs in about half of critically ill patients.  Some fairly simple measures may reduce the risk of delirium.  When it occurs, delirium is a diagnostic challenge because occasionally it can be a sign of undiagnosed underlying illness.  Treatment is challenging, with little evidence to support most of the standard therapies.

EMCrit Project by Josh Farkas.

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PulmCrit: No more antipsychotics for delirium? Not so fast! http://emcrit.org/pulmcrit/antipsychotics-delirium/ http://emcrit.org/pulmcrit/antipsychotics-delirium/#comments Mon, 05 Nov 2018 13:29:14 +0000 http://emcrit.org/?p=455111 Recently the MINDS-USA trial evaluated the use of haloperidol or ziprasidone for delirium in critical illness.  Before jumping into the results of this study, it will help to establish a couple of foundational principles.

EMCrit Project by Josh Farkas.

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PulmCrit- Does the HIGH trial debunk high-flow nasal cannula? http://emcrit.org/pulmcrit/pulmcrit-does-the-high-trial-debunk-high-flow-nasal-cannula/ http://emcrit.org/pulmcrit/pulmcrit-does-the-high-trial-debunk-high-flow-nasal-cannula/#comments Thu, 01 Nov 2018 13:01:45 +0000 http://emcrit.org/?p=455050 High-flow nasal cannula (HFNC) has become popular for the hypoxemic respiratory failure, driven partially by the FLORALI trial.1  Recently, the HIGH trial evaluated the ability of HFNC to reduce mortality among immunocompromised patients with acute hypoxemic respiratory failure.2  HFNC failed to improve mortality or significantly reduce intubation rates. Popular narrative about this trial A common […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Anemia & transfusion targets http://emcrit.org/pulmcrit/transfusion/ http://emcrit.org/pulmcrit/transfusion/#comments Wed, 31 Oct 2018 12:26:30 +0000 http://emcrit.org/?p=455063 Most patients in the ICU will become anemic.  This chapter explores prevention, evaluation, and treatment of anemia in the ICU.  Causes of new-onset anemia in the ICU are distinct from the causes of anemia seen in the outpatient clinic, so the approach should be appropriately tailored to the critical care environment.   

EMCrit Project by Josh Farkas.

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PulmCrit- SUP-ICU: Is pantoprazole the elixir of life? Should it be? http://emcrit.org/pulmcrit/sup-icu/ http://emcrit.org/pulmcrit/sup-icu/#comments Tue, 30 Oct 2018 11:43:13 +0000 http://emcrit.org/?p=455011 SUP-ICU is a massive, modern RCT of stress ulcer prophylaxis (SUP) in the ICU. With 3298 patients, it is larger than many meta-analyses of SUP. Its primary mortality endpoint is deeply flawed.  However, the study still provides a wealth of information about SUP in the ICU.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Acute pancreatitis http://emcrit.org/pulmcrit/pancreatitis/ http://emcrit.org/pulmcrit/pancreatitis/#comments Thu, 25 Oct 2018 19:29:15 +0000 http://emcrit.org/?p=454895 Management of severe pancreatitis has remained in a state of controlled chaos and persistent debate for years (mirroring evolution in our treatment of septic shock).  This confusion shows no signs of abating in the near future.  This chapter explores a reasonable approach to pancreatitis, with the caveat that there is very little evidence available to guide our combat against this challenging foe.  

EMCrit Project by Josh Farkas.

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PulmCrit- Ketamine for alcohol withdrawal? http://emcrit.org/pulmcrit/ketamine-alcohol-withdrawal/ http://emcrit.org/pulmcrit/ketamine-alcohol-withdrawal/#comments Mon, 22 Oct 2018 11:55:42 +0000 http://emcrit.org/?p=454836 Recent publications have explored the role of ketamine in alcohol withdrawal.  Ketamine undoubtedly has some outstanding properties, which make it well suited for  this task.  The challenge is integrating ketamine into a unified, coherent treatment strategy. 

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: severe heart failure & cardiogenic shock http://emcrit.org/pulmcrit/heart-failure/ http://emcrit.org/pulmcrit/heart-failure/#comments Wed, 17 Oct 2018 12:46:00 +0000 http://emcrit.org/?p=454739 Management of severe heart failure and cardiogenic shock is difficult.  There is a notable lack of high-quality evidence regarding the sickest patients.  Treatment strategies validated among more stable patients may not be applicable to the most unstable heart failure patients.   

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Hypoglycemia http://emcrit.org/pulmcrit/hypoglycemia/ http://emcrit.org/pulmcrit/hypoglycemia/#comments Wed, 10 Oct 2018 10:48:25 +0000 http://emcrit.org/?p=454580 Severe hypoglycemia can be scary, especially when the patient isn't responding to front-line therapies (e.g. IV dextrose).  However, some unconventional tools and an organized approach can make this extremely manageable.

EMCrit Project by Josh Farkas.

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PulmCrit- Alcohol Withdrawal: One order to sedate them all http://emcrit.org/pulmcrit/phenobarbital-oks/ http://emcrit.org/pulmcrit/phenobarbital-oks/#comments Mon, 08 Oct 2018 10:47:14 +0000 http://emcrit.org/?p=454508 I should do a formal retrospective cohort study on this, but I don’t have time.  Fortunately, the ICU group at Northshore/Long Island Jewish has done exactly that.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Bradycardia http://emcrit.org/pulmcrit/bradycardia/ http://emcrit.org/pulmcrit/bradycardia/#comments Wed, 03 Oct 2018 13:36:20 +0000 http://emcrit.org/?p=454444 Bradycardia emergencies are uncommon, but these cases can go sideways fast.  An appropriately aggressive approach is needed to avoid cardiac arrest.  Sometimes the answer is as simple as the appropriate epinephrine dose.  

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: community-onset pneumonia http://emcrit.org/pulmcrit/pneumonia/ http://emcrit.org/pulmcrit/pneumonia/#comments Thu, 27 Sep 2018 11:17:14 +0000 http://emcrit.org/?p=454284 Sir William Osler called pneumonia "the captain of the men of death."  Over a century later, pneumonia remains the leading cause of infectious death in the developed world.  

EMCrit Project by Josh Farkas.

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PulmCrit- Solving the OPTALYSE PE riddle: We’re dosing tPA wrong http://emcrit.org/pulmcrit/pulmcrit-solving-the-optalyse-pe-riddle-were-dosing-tpa-wrong/ http://emcrit.org/pulmcrit/pulmcrit-solving-the-optalyse-pe-riddle-were-dosing-tpa-wrong/#comments Mon, 24 Sep 2018 11:00:08 +0000 http://emcrit.org/?p=454138 Occasionally in science we encounter a truly bizarre result.  Our natural inclination is to ignore the bizarre result.  It’s jarring.  It creates cognitive dissonance, challenging our understanding of the world.  However, struggling to understand the bizarre result can reset our perspective.  It’s often the bizarre, unexpected result that changes everything. 

EMCrit Project by Josh Farkas.

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IBCC Chapter & Cast: GI Hemorrhage http://emcrit.org/pulmcrit/gi-hemorrhage/ http://emcrit.org/pulmcrit/gi-hemorrhage/#comments Wed, 19 Sep 2018 11:11:36 +0000 http://emcrit.org/?p=453974 GI bleeding is bread and butter critical care.  However, there are a lot of nuances - especially regarding variceal bleeding and new approaches to hematochezia.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Troponin elevation in non-cardiac critical illness http://emcrit.org/pulmcrit/troponin/ http://emcrit.org/pulmcrit/troponin/#comments Wed, 12 Sep 2018 10:09:46 +0000 http://emcrit.org/?p=453793 How should we evaluate for myocardial ischemia in a critically ill patient admitted for some other problem (e.g. pneumonia)?  What does it mean if their troponin is elevated?

EMCrit Project by Josh Farkas.

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PulmCrit- Sepsis Research Rant: More fake news, less real news http://emcrit.org/pulmcrit/fake-news/ http://emcrit.org/pulmcrit/fake-news/#comments Mon, 10 Sep 2018 10:46:28 +0000 http://emcrit.org/?p=453711 The following rant focuses on sepsis research, but these principles are universal.  I apologize for the agitated nature of this post, but I just can’t hold it in any longer.  If I read one more correlational study which tries to imply causation, I might just explode.  In order to prevent burnout, I’m going to journal these thoughts instead.  So, hang on to your hats, because things are going to get a bit heated.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Anatomy of a DKA resuscitation http://emcrit.org/pulmcrit/dka/ http://emcrit.org/pulmcrit/dka/#comments Thu, 06 Sep 2018 13:03:47 +0000 http://emcrit.org/?p=453391 EMCrit Project by Josh Farkas.

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Announcement: Launching the Internet Book of Critical Care (IBCC) http://emcrit.org/pulmcrit/announcement-launching-the-internet-book-of-critical-care-ibcc/ http://emcrit.org/pulmcrit/announcement-launching-the-internet-book-of-critical-care-ibcc/#comments Tue, 04 Sep 2018 11:40:18 +0000 http://emcrit.org/?p=453546 Several years ago a mentor suggested that I write a book.  I nearly laughed at her.  A book??  Inconceivable!  Who would buy it?  Would they actually read it?  Would it be there at 3 AM when they needed it?  How could it be updated?  A physical book didn't seem compatible with the breakneck speed of critical care or our internet-based culture.

EMCrit Project by Josh Farkas.

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PulmCrit- The hidden fragility of meta-analyses: case study of the IOTA trial http://emcrit.org/pulmcrit/meta/ http://emcrit.org/pulmcrit/meta/#comments Mon, 27 Aug 2018 12:09:16 +0000 http://emcrit.org/?p=453179 Meta-analyses are widely assumed to be robust, without any attempt to test their fragility. This post describes two techniques to evaluate the fragility of a meta-analysis

EMCrit Project by Josh Farkas.

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PulmCrit: A-lines in septic shock: the wrist versus the groin http://emcrit.org/pulmcrit/a-line/ http://emcrit.org/pulmcrit/a-line/#comments Mon, 13 Aug 2018 11:01:43 +0000 http://emcrit.org/?p=452884 Historically, emphasis has rested on the distinction between noninvasive versus invasive BP (e.g., cuff pressure vs. radial arterial pressure).  Attention focused on whether noninvasive oscillometric BP monitoring is adequate. Meanwhile, it has been assumed that all invasive BP measurement sites are created equal.

EMCrit Project by Josh Farkas.

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PulmCrit- Can we fix a broken circadian clock with melatonin? http://emcrit.org/pulmcrit/melatonin/ http://emcrit.org/pulmcrit/melatonin/#comments Mon, 30 Jul 2018 15:24:55 +0000 http://emcrit.org/?p=452481 Circadian rhythms and melatonin are best known for their relationship to sleep.  However, they have a much broader range of functions.  Circadian rhythms cause many organs to enter a resting state at night (e.g. heart rate decreases, cortisol levels increase).  

EMCrit Project by Josh Farkas.

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PulmCrit Wee – Metabolic resuscitation for severe pneumonia? http://emcrit.org/pulmcrit/vitamin-c-pneumonia/ http://emcrit.org/pulmcrit/vitamin-c-pneumonia/#comments Thu, 19 Jul 2018 12:33:19 +0000 http://emcrit.org/?p=452316 Metabolic resuscitation for sepsis is currently quite controversial.  Marik et al. published a before-after study in 2017 describing the combination of hydrocortisone, ascorbate, and thiamine for septic shock. That study incited a media storm of surprising intensity.  Currently, several multi-center RCTs are underway to answer this question more definitively.  In the interim, some additional before/after trials may emerge.  These studies likely won’t answer the question, but they may provide us with some clues about whether metabolic resuscitation is on the right track.

EMCrit Project by Josh Farkas.

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PulmCrit- Could the Furosemide Stress Test clarify resuscitative goals? http://emcrit.org/pulmcrit/furosemide-stress-test/ http://emcrit.org/pulmcrit/furosemide-stress-test/#comments Mon, 16 Jul 2018 11:30:05 +0000 http://emcrit.org/?p=452223 Imagine that you admit a patient with septic shock.  You resuscitate the patient as best you can with inopressors, fluids, and antibiotics. An adequate blood pressure is achieved.  A reasonable amount of fluid is administered.  Despite all these measures, the urine output remains minimal.  What should you do next?

EMCrit Project by Josh Farkas.

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PulmCrit- A better approach to Torsade de Pointes http://emcrit.org/pulmcrit/tdp-magnesium/ http://emcrit.org/pulmcrit/tdp-magnesium/#comments Mon, 02 Jul 2018 10:52:54 +0000 http://emcrit.org/?p=451968 A common approach to TdP is shown above.  The initial episode is controlled with magnesium and perhaps defibrillation.  The patient is sent to ICU for close observation.  Usually the patient will be fine, but sometimes TdP does recur.  Recurrence triggers second-tier therapies, often including overdrive pacing.

EMCrit Project by Josh Farkas.

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PulmCrit: pH-guided fluid resuscitation & BICAR-ICU http://emcrit.org/pulmcrit/bicar-icu/ http://emcrit.org/pulmcrit/bicar-icu/#comments Wed, 27 Jun 2018 10:43:37 +0000 http://emcrit.org/?p=451840 The use of bicarbonate is a source of eternal disagreement.  Bicarbonate has a shameful history of being abused in situations where it’s unhelpful (e.g. cardiac arrest).  This has impugned its reputation, giving it an aura of ignorance and failure.  Consequently, bicarbonate is underutilized in some situations where it might actually help.

EMCrit Project by Josh Farkas.

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PulmCrit- Should we monitor fibrinogen during full- & half-dose PE thrombolysis? http://emcrit.org/pulmcrit/fibrinogen_pe/ http://emcrit.org/pulmcrit/fibrinogen_pe/#comments Mon, 11 Jun 2018 10:48:45 +0000 http://emcrit.org/?p=451480 No high-quality evidence exists on fibrinogen monitoring in PE.  Most practitioners don’t check fibrinogen levels for patients getting TPA for PE.  This is a bit paradoxical, because fibrinogen is usually monitored in patients receiving catheter-directed thrombolysis – a procedure involving lower doses of TPA with a markedly lower risk of intracranial hemorrhage.

EMCrit Project by Josh Farkas.

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PulmCrit- High dose vasopressors: Never surrender http://emcrit.org/pulmcrit/high-dose-vasopressor/ http://emcrit.org/pulmcrit/high-dose-vasopressor/#comments Mon, 04 Jun 2018 15:51:45 +0000 http://emcrit.org/?p=451328 Every hospital and pharmacopeia have their own “maximum dose” of vasopressors. Which one is correct?

EMCrit Project by Josh Farkas.

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PulmCrit- Ten dubious beliefs in neurocritical care http://emcrit.org/pulmcrit/dubious-neurocritical/ http://emcrit.org/pulmcrit/dubious-neurocritical/#comments Mon, 21 May 2018 10:57:00 +0000 http://emcrit.org/?p=451070 Recently Geert Meyfroidt published an article in Intensive Care Medicine describing ten false beliefs in neurocritical care shown here: It's a great article, but I think they could have been more aggressive about challenging neurocritical care dogmas (1).  In response, here is a list of ten dubious beliefs that goes farther to challenge the status quo.  […]

EMCrit Project by Josh Farkas.

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PulmCrit- Montreal Hospitalist & Resuscitationist Conference FOAMed http://emcrit.org/pulmcrit/hr/ http://emcrit.org/pulmcrit/hr/#comments Wed, 16 May 2018 13:44:00 +0000 http://emcrit.org/?p=450361 I recently got back from the inaugural Hospitalist & Resuscitationist conference, a fantastic FOAMy conference in Montreal organized by Phillipe Rola (@ThinkingCC).  It was inspiring to participate alongside fantastic folks including Rory Speigel (@EMNerd), Jon-Emile Kenny (@heart_lung), Kylie Baker (@kyliebaker88), Lawrence Lynn(@PatientStormDoc), Andre Denault, and Segun Olusanya (@iceman_ex).  Screencasts of my talks, audio clips, some videos […]

EMCrit Project by Josh Farkas.

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PulmCrit- Drowned Airway Algorithm: Cut to the chase http://emcrit.org/pulmcrit/drowned-airway-algorithm/ http://emcrit.org/pulmcrit/drowned-airway-algorithm/#comments Mon, 07 May 2018 11:02:10 +0000 http://emcrit.org/?p=450701 The literature describes various techniques for the drowned airway.  However, there doesn’t appear to be any airway algorithm which integrates these into a coherent strategy.  A collection of airway tricks without any plan is a formula for disaster. 

EMCrit Project by Josh Farkas.

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Petition to retire the surviving sepsis campaign guidelines http://emcrit.org/pulmcrit/ssc-petition/ http://emcrit.org/pulmcrit/ssc-petition/#comments Wed, 02 May 2018 10:47:57 +0000 http://emcrit.org/?p=450561 We are disseminating an international petition that will allow clinicians to express their displeasure and concern over these guidelines.  If you believe that our septic patients deserve more evidence-based guidelines, please stand with us. 

EMCrit Project by Josh Farkas.

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PulmCrit- Shrug Technique for US-guided subclavian lines http://emcrit.org/pulmcrit/shrug-subclavian/ http://emcrit.org/pulmcrit/shrug-subclavian/#comments Mon, 23 Apr 2018 12:27:17 +0000 http://emcrit.org/?p=450471 The CDC guidelines recommend placing subclavian lines to reduce the risk of catheter-related bloodstream infections.  Meanwhile, mounting evidence suggests that we should probably be placing lines with ultrasound guidance.  Unfortunately, the ultrasound-guided subclavian can be tricky.  This post describes a slight modification that could make the technique easier and safer.

EMCrit Project by Josh Farkas.

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PulmCrit- .050 shades of grey in p-value cutoffs http://emcrit.org/pulmcrit/p-value-cutoffs/ http://emcrit.org/pulmcrit/p-value-cutoffs/#comments Mon, 09 Apr 2018 11:00:15 +0000 http://emcrit.org/?p=449925 We have a love-hate relationship with the p-value cutoff of <0.05.  A p-value right below this cutoff (say, p=0.04) actually constitutes a surprisingly weak level of evidence (1).  Thus, the idea of lowering the p-value cutoff has been around for a while.  Unfortunately, this wouldn't really fix our problems with p-values.

EMCrit Project by Josh Farkas.

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PulmCrit- APROCCHSS vs. ADRENAL: Are we asking the right question? http://emcrit.org/pulmcrit/aprocchss/ http://emcrit.org/pulmcrit/aprocchss/#comments Mon, 26 Mar 2018 11:00:05 +0000 http://emcrit.org/?p=449660 ADRENAL and APROCCHSS were both designed with mortality as a primary endpoint.  They reached opposite conclusions:  steroid had no effect on mortality in ADRENAL, whereas it improved mortality in APROCCHSS.  Why?

EMCrit Project by Josh Farkas.

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