preamble CRASH-3 is the latest massive, pragmatic multi-center RCT brought to us by the London School of Hygiene and Tropical Medicine Trials Unit. These investigators have created an extensive network of hospitals throughout the world with the capability of performing truly impressive trials. Especially in the critical care arena, these trials have uniquely high power […]
IBCC asthma chapter post-publication peer review by Weingart
Sometimes muggles criticize FOAM as lacking peer review, but that simply reflects a misunderstanding of the way peer review works here. FOAMed operates off a post-publication peer review system. This typically occurs mostly in the comments section of each blog or chapter (with some on twitter as well). Unlike journals, anyone is free to leave […]
IBCC chapter & cast – Diffuse alveolar hemorrhage & ANCA vasculitis
Diffuse alveolar hemorrhage is encountered uncommonly, but it is useful to have a general understanding of this. Many etiologies can cause diffuse alveolar hemorrhage, with pulmonary vasculitis being perhaps the most widely feared. This chapter explores how to sift through the differential diagnosis of diffuse alveolar hemorrhage and, if vasculitis is suspected, how to initiate […]
IBCC chapter & cast – Asthma
Severe asthma is a challenging topic, because this spans a lot of different patient phenotypes with varying severity and physiology. This chapter attempts to outline some general principles to guide management, but ultimately clinical judgement and serial evaluation at the bedside will trump all of this. The rarity, acuity, and heterogeneity of severe asthma make […]
PulmCrit- Hypothermia for non-shockable arrest: let’s not get hot-headed about this
background Fever is harmful in post-arrest patients. This creates confusion in studies of hypothermia in post-arrest patients: is the benefit of hypothermia due to fever avoidance, due to a benefit from hypothermia itself, or perhaps due to both? Seminal studies in the early 2000s found mortality benefit from application of hypothermia to 33C after cardiac […]
PulmCrit- CITRIS-ALI: Can a secondary endpoint stage a coup d’état?
background on IV vitamin C We live in divided times. Paul Marik’s study on using vitamin C in sepsis was perhaps the most polarizing publication in recent memory (aside from perhaps the Mueller report). It was lauded by some, yet derided just as strongly by others. Unfortunately, the kerfuffle surrounding this study overshadowed the larger […]
IBCC chapter & cast – Metabolic Alkalosis
Metabolic alkalosis is fairly common among hospitalized patients. The most severe cases are often due to large-volume diuresis (deresuscitation), massive transfusion, or ongoing nasogastric suction. Many patients will respond to simple resuscitation with normal saline (an acidotic fluid which is perfect here). However, more severe or complex cases will require a multi-modal strategy which utilizes […]
PulmCrit – The Crashing Asthmatic with Leo Stemp
Today will feature a guest post with Leo Stemp exploring some bleeding-edge concepts. Very soon, an Internet Book of Critical Care chapter will round things out with a broader look at this disease. Leo Stemp trained first in critical care (including medical school at Harvard, internal medicine residency at Mount Sinai, and a fellowship at […]
IBCC chapter & cast – Non-Anion Gap Metabolic Acidosis (NAGMA)
Non-Anion Gap Metabolic Acidosis (NAGMA) has a broad differential diagnosis. Often the cause is obvious, but otherwise this leads to a rat’s nest of various forms of renal tubular acidosis (RTA). Fortunately, appropriate treatment generally doesn’t require immediate diagnosis of the specific cause of the NAGMA. So have no fear – give the evaluation an […]
IBCC chapter & cast: Anion-Gap Metabolic Acidosis
Anion gap metabolic acidosis is generally the most worrisome pH abnormality. Many of the causes of anion gap elevation reflect a life-threatening problem (e.g. hyperlactatemia, shock, diabetic ketoacidosis, toxic alcohol poisoning). Particularly if the anion gap elevation is a new finding, this mandates immediate investigation (and sometimes, simultaneous resuscitation). This chapter explores the causes of […]
IBCC chapter & cast – Approach to pH diagnosis
According to Albert Einstein, “Everything should be made as simple as possible, but not simpler.” This is a similar sentiment to Occam’s Razor. Acid-base analysis is a good example of this principle. It’s possible to make things extraordinarily fancy and complex. To analyze pH status we could obtain an ABG, complete blood count, calcium, magnesium, […]
IBCC chapter & cast – Submassive & Massive PE
PE is the third leading cause of vascular mortality, after myocardial infarction and stroke. It is an enormously heterogeneous and unpredictable disease, which makes treatment difficult. As such, it should not be surprising that PE therapy remains highly controversial. For example, the new European Society of Cardiology guidelines recommend anticoagulation and watchful waiting for high-risk […]
IBCC chapter & cast – Anticoagulation reversal
We are frequently faced with patients who require reversal of anticoagulation due to hemorrhage or an emergent procedure. This has grown rather complicated, due to the emergence of numerous new anticoagulants and reversal agents. Furthermore, new evidence is emerging regarding the reversal of old agents (e.g. the PATCH trial regarding platelet transfusion in patients on aspirin).
PulmCrit- How to use IV epinephrine for anaphylaxis
When treating anaphylaxis, epinephrine is generally given via an intramuscular (IM) route. This is well established to be effective and life-saving. One advantage of IM administration is immediate use (without requiring intravenous access), including by patient auto-injection. IM epinephrine is doubtless the best approach for patient self-treatment, for first responders, and for immediate treatment in […]
IBCC chapter & cast: Tumor Lysis Syndrome
Tumor lysis syndrome isn’t encountered very often in critical care, but we will see the most extreme extent of this illness. Within the last decade, rasburicase has been a game-changer here. Understanding some basic physiology will guide the optimal diagnosis and treatment of tumor lysis syndrome in the post-rasburicase era. The IBCC chapter is located […]
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