A peasant traveling home at dusk sees a bright light traveling along ahead of him. Looking closer, he sees that the light is a lantern held by a ‘dusky little figure’, which he follows for several miles. All of a sudden he finds himself standing on the edge of a vast chasm with a roaring […]
Secondary Bacterial Peritonitis
0 Introduction with a case 0 A patient with advanced alcoholic cirrhosis presents to the hospital with fever and altered mental status. Examination is notable for abdominal distention with rebound tenderness. Bedside ultrasound reveals a large amount of ascites, which is carefully sampled revealing a cloudy fluid with 15,000 neutrophils/uL and a differential of 90% neutrophils (a […]
High-flow nasal cannula to prevent post-extubation respiratory failure
0 Background: Post-extubation failure and noninvasive ventilation (NIV) 0 Post-extubation respiratory failure requiring re-intubation is a major setback for any critically ill patient. Current evidence mainly involves the pre-emptive use of NIV to reduce post-extubation failure, particularly in hypercapnic COPD patients. However, in practice this is difficult to implement widely. Except for the sickest COPD […]
EMCrit 128 – Pulmonary Embolism Treatment Options and the PEAC Team with Oren Friedman ( PERT Teams )
All things PERT and PE treatment options
Eight pearls for the crashing patient with massive PE
0 Introduction 0 Literature on massive PE focuses mostly on how to deal with the clot while less attention is spent on other aspects of management. This post will focus on such aspects, especially hemodynamic resuscitation of massive PE. There is nearly no clinical data, forcing us to extrapolate between limited data, hemodynamic theory, and […]
Expert Commentary on EMCrit
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Preoxygenation & apneic oxygenation using a nasal cannula
0 Starting Point: We do a bad job at preoxygenation 0 We could do better at preoxygenating patients before emergent intubations. In my experience the most commonly used device for preoxygenation is a bag-valve mask, which has many pitfalls. We often accept a poor mask seal in efforts to remain gentle with awake patients. […]
“The Adventure of the Golden Standard”
We have all been told ghost stories and fairy tales. Campfire fables intended to frighten the gullible populace into behaving in a manner deemed appropriate. Even in Emergency Medicine we have our fair share of ghost stories. Most notably we are taught from an early age to fear and respect the clinically occult pulmonary embolism. […]
EMCrit 127 – The Oxylator with Jim DuCanto
BVMs are ridiculously crappy and downright dangerous. The solution? the Oxylator
Dexmedetomidine to facilitate noninvasive ventilation
Introduction 0 Noninvasive ventilation (NIV) has recently emerged as a fundamental treatment for patients with acute exacerbation of obstructive lung disease or cardiogenic pulmonary edema, often avoiding intubation. However, some patients have difficulty tolerating this therapy due to anxiety. Dexmedetomidine (PRECEDEX) is an attractive sedative to manage this problem, since it may be titrated and […]
SMACC-Back – On the Beliefs of Early Adopters and Straw Men
The First SMACC-Back from SMACCgold
Thrombolysis reduces mortality in submassive PE
Introduction 0 There has been exciting research into submassive PE (a.k.a., intermediate-risk PE) recently with the release of MOPETT, PEITHO, TOPCOAT, and ULTIMA. In a prior blog post I discussed these studies in detail and suggested that our approach to PE is based on tradition rather than evidence. In summary, heparin is viewed as the […]
MOTR: Cliff Reid on When Should Stop Resuscitation
Cliff Reid on When Should Resus Stop from SMACCgold
Cardiogenic shock following cardioversion of atrial flutter
0 Introduction with a case 0 Once upon a time at Genius General Hospital a 63-year-old woman was admitted with lower extremity edema and orthopnea. Her past medical history was unremarkable. She was noted to be in atrial flutter with a heart rate in the 120s and a blood pressure ranging from 100-120 mm systolic. She […]
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