Hypercalcemia isn’t a particularly common cause of critical illness, but when encountered this requires immediate treatment. Fortunately, advances in the treatment for hypercalemia have clarified how to do this safely and definitively. Forced diuresis with furosemide has largely fallen by the wayside, simplifying fluid and electrolyte management. The cornerstone of therapy is generally simultaneous initiation of calcitonin and an IV bisphosphonate.
PulmCrit- TEG for cirrhotic coagulopathy: Time for clinical implementation?
Introduction Traditional coagulation studies (especially the INR) fail miserably in cirrhosis. Thromboelastography (TEG) is a superior approach for understanding the global balance of pro-coagulants versus anti-coagulants in these patients. This isn’t anything particularly new – for example, it was explored in this post from 2015 (if you’re not familiar with this concept already, it’s explained […]
IBCC chapter & cast: Serotonin syndrome
Serotonin syndromes comes up a lot in critical care medicine. Sometimes we are admitting patients because of a primary diagnosis of serotonin syndrome. Other times we are afraid of causing serotonin syndrome ourselves, due to polypharmacy. In both scenarios, there may be uncertainty regarding whether or not a patient has serotonin syndrome. This chapter explores […]
IBCC chapter & cast: Tick-borne infections
It’s spring in Vermont… when a young intensivist’s thoughts go from fancy to tick-borne diseases. Climate shifts are causing an increase in tick-borne illnesses, such that these are now considered emerging infections in many areas (including the northeast United States and Canada). These diseases can be extremely difficult to diagnose, as they will often present with a nonspecific flu-like illness and may subsequently progress to multi-organ failure. Misdiagnosis of a tick-borne illness as bacterial septic shock would lead to inadequate treatment, as these diseases require specific antibiotic therapy (usually doxycycline). This chapter focuses on diagnosis and empiric therapy for these very challenging infections.
PulmCrit: Myth-busting the fluid bolus
For centuries, medical experts practiced bloodletting for a variety of ailments. This was widely believed to rid the body of evil humors. When patients didn’t respond well, this was believed to reflect an inadequate or delayed bloodletting. Practitioners competed to see who could partake in the most rapid and aggressive bloodletting.
IBCC chapter & cast: Hepatic Encephalopathy
Hepatic encephalopathy is a common cause of ICU admission, as well as a common complication of ICU admission for other indications (e.g. gastrointestinal hemorrhage). At first the intubated patient with hepatic encephalopathy may seem a bit bewildering (will they ever wake up??). However, an organized and aggressive strategy combined with some patience is generally sufficient […]
PulmCrit: Neutrophil-Lymphocyte Ratio (NLR): Free upgrade to your WBC
introduction The neutrophil/lymphocyte ratio (NLR) has been gaining increasing attention across many fields of medicine within the past five years. Currently, there are 2,230 publications about this in PubMed, mostly within the past few years. This post will attempt to create a framework for understanding this ratio. overview definition & physiology The NLR is simply […]
PulmCrit: Validation of test-dose strategy for beta-lactam allergies
Background Kimberly Blumenthal and colleagues at the Massachusetts General Hospital have been performing groundbreaking work on beta-lactam allergies. Their work forms the foundation for much of the IBCC chapter on beta-lactam allergies (you might want to read it before this post, but if you don’t have time, a one-minute synopsis is below). One fundamental technique […]
IBCC chapter & cast: Rhabdomyolysis
Before writing this chapter I though I understood rhabdomyolysis fairly well. I had treated many cases, read about it in a few books, and heard a lecture or two on it. However, writing this chapter has forced me to realize that I didn’t really understand rhabdo well at all. This disease is generally poorly understood, […]
IBCC chapter & cast: hypophosphatemia and hyperphosphatemia
Phosphate is the forgotten electrolyte of critical care. Unlike other electrolytes, phosphate doesn’t participate in the generation of electrochemical gradients (like calcium, magnesium, and potassium) or govern tonicity (like sodium). Thus, moderate perturbations in phosphate are generally asymptomatic. However, phosphate does participate in many essential cellular processes, so true intracellular hyphophosphatemia can cause severe symptoms. […]
PulmCrit: Checkpoint inhibitors… for septic shock??
Background Septic shock is generally conceptualized as a state of pathological immune hyperactivity. Consequently, decades of work on immunomodulation in sepsis have focused on immunosuppressive medications (e.g. steroid, TNF-inhibitors, IL-1 inhibitors). Although most of these interventions haven’t worked, steroid offers some benefits and IL-1 receptor antagonism shows promise for a subset of patients.1 The natural […]
IBCC chapter & cast: The myth of contrast nephropathy
Does contrast nephropathy exist? Vigorous debate has been ongoing about this dating back to 2013.1 Hundreds of studies on the topic ultimately reveal no convincing evidence that contrast nephropathy exists. However, it’s unethical to perform a prospective RCT, so it’s impossible to ever prove this. This has left us in an evidentiary limbo – we […]
IBCC chapter & cast – Endocarditis
Endocarditis is a classic disease of emergency medicine, inpatient medicine, and critical care. The opioid epidemic has caused a surge of endocarditis diagnoses, reminding us of the myriad ways that this disease can present itself.
PulmCrit- Why most diagnostic procedures aren’t beneficial
We often assume that diagnostic procedures will help patients. A lot of training goes into learning how to do these procedures. Procedures are dramatic. We like performing them. Patients are impressed, perceiving that we are “doing” something for them. Everything is awesome.However, when strict evidence-based medicine is applied to procedures, they are often less impressive.
IBCC chapter: VT storm
VT storm refers to recurrent episodes of VT/VF. Although any individual episode of VT can be broken, the overall process of recurrent arrests (or ICD shocks) creates a vicious cycle. Aggressive management is required with intubation, deep sedation, antiarrhythmics, and sympatholysis. Given the rarity of this condition, it’s difficult to obtain high-level evidence or extensive experience.
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