EMCrit

Introduction with a case Once upon a time at Genius General Hospital, I arrived a bit early for a shift.  The outgoing attending was happy to see me:  "Hi Josh, you got here just in time to intubate the patient in Bed 8.  He was supposed to get an upper endoscopy with ketamine sedation, but he couldn't be sedated."The patient in Bed 8 was a 40-year-old man with a history … [Read more...]

The PulmCrit blog is about controversies in adult critical care.  Everything in the blog is controversial.  As such, I always encourage readers to think critically about the material and reach their own conclusions.  There are many situations where smart people presented with the same data will reach different conclusions.  That diversity of opinions is part of what makes … [Read more...]

There is no room for error when diagnosing brain death.  Incorrect diagnosis causes inappropriate withdrawal of care.  However, delayed or missed diagnoses lead to futile care and lost opportunities for organ donation. American neurologists do not have a consistent rationale for accepting brain death as death, nor a clear understanding of diagnostic tests for brain death … [Read more...]

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 been diagnosed based on other features (e.g., … [Read more...]

Based on the Rivers trial of early goal-directed therapy, central venous oxygen saturation (cvO2%) emerged as a resuscitation target.  This was recommended for over a decade until the PROCESS, PROMISE, and ARISE trials demonstrated that cvO2% monitoring was unnecessary.  Consequently, this has largely fallen by the wayside.However, one niche role of cvO2% in the ICU has … [Read more...]