EMCrit Project

Controlled thrombolysis using a slow 25-mg alteplase infusion with protocoled monitoring might offer patients the benefit of lytic therapy with an extremely low risk of severe hemorrhage.

Ultrasound-assisted catheter-directed thrombolysis is increasingly popular for submassive PE. Unfortunately, the actual mechanism of action of this therapy remains unclear.

Early in my training I had a few comatose meningitis patients. They were admitted, given antibiotics, and supported on a ventilator. They died. For a while, I believed that this condition was fairly hopeless. Then I encountered a comatose young man with meningitis due to adjacent mastoiditis. His lumbar puncture opening pressure was ~50cm. Following mastoidectomy and temporary placement of a lumbar drain, he recovered. Since then, I have been increasingly aggressive about managing this. Some patients have responded surprisingly well.

Traditionally, coagulation management in patients with cirrhosis has focused largely on using large volumes of FFP to decrease the INR. However, recent evidence indicates that INR prolongation in these patients is nonspecific and that FFP usually isn’t helpful.

Routinely obtaining an ABG or VBG is widely recommended, for example in both American and British guidelines. Why? Is this helping our patients, or is it something that we do out of a sense of habit or obligation?

Introduction  . It has long been known that some macrolides (e.g. erythromycin) cause torsade de pointes.  However, azithromycin has a much lower affinity for cardiac potassium channels than erythromycin, so it has less effect on the heart.  For many years it was believed that azithromycin lacked cardiac toxicity. . Controversy was sparked in 2012 when […]

. Background:  Publication bias . Over the last several years, publication bias has received a considerable amount of attention.  In its most blatant form, this is when a drug company sponsors several trials, but only publishes the trials which yeild positive results.  Growing awareness of this problem has led to the development of trial registries, […]

. Introduction with a clinical question . A 50-year-old woman with no prior medical problems was admitted to Genius General Hospital with severe influenza pneumonia and acute kidney injury.  She was transferred to the ICU and treated with high-flow nasal cannula oxygen support.  Over time she gradually improved with decreasing oxygen requirements and improving renal […]

. Introduction:  Perpetual controversy . The use of magnesium for AF has been a controversial topic for decades.  Magnesium is a normal electrolyte, so it is cheap and has an excellent safety profile.  Ironically, this is also magnesium’s Achilles heel, because this has caused the pharmaceutical industry to have no interest in it.  This leaves […]

  . Introduction . In 2008 and 2013, two prospective RCTs from Greece reported benefits from the combination of vasopressin, steroids, and epinephrine (VSE) for in-hospital cardiac arrest.  However, other studies investigating the addition of vasopressin alone to epinephrine have been negative.  Consequently, vasopressin has been removed from the AHA/ACC algorithms, with a specific recommendation […]

[PLEASE NOTE:  For the most complete & updated material on alcohol withdrawal, please see the Internet Book of Critical Care Chapter on this topic here] Case example   . A middle-aged man was admitted to the ICU for refractory alcohol withdrawal.  Prior to arriving in the ICU he had been treated aggressively with an escalating […]

. Introduction . Resuscitation with large volumes of normal saline (NS) causes hyperchloremic metabolic acidosis.  Some evidence suggests that hyperchloremic metabolic acidosis may impair renal function, but the clinical relevance of this remains unclear.  If hyperchloremic metabolic acidosis is truly detrimental, this would be one argument to use balanced crystalloids rather than NS.  . . […]

. A perplexing case . A young man with a history of seizures and alcoholism presented with a generalized seizure.  His seizure responded to lorazepam, but he was intubated for airway protection and was transferred to the Genius General ICU.  He was also loaded with levtiracetam to prevent further seizures.  . Overnight he developed agitation.  Despite […]

  . Case: An unusual ICU referral . Some years ago at Genius General Hospital, the ICU was asked to accept a patient from the medicine ward with cirrhosis, confusion, and hyponatremia (Na 125 mM) for hypertonic saline therapy.  There was concern that the patient’s confusion was due to his hyponatremia.  . Chart review showed […]

. Introduction with a case . Imagine an elderly patient presenting with hypovolemic hyponatremia (sodium of 115 mM) and moderate confusion.  How would you treat this patient? . The typical approach might be a slow infusion of 3% sodium chloride.  The presence of neurologic symptoms supports the use of hypertonic saline.  However, patients with hypovolemic […]