EMCrit Project

Acute promyelocytic leukemia (APL) is a unique leukemia, with particular importance to resuscitationists.  Unlike most leukemias, the highest rate of mortality occurs at the time of diagnosis (a phenomenon known as “early deaths”).  If patients are able to survive the initial phase of illness, the cure rate is extremely high (>90%).  Aggressive support in the […]

A multi-center RCT was released yesterday comparing rocuronium versus succinylcholine.  It’s a thoroughly uninformative study, so at first I wasn’t planning to write about it.  But then I realized that the study, in its very myopia, is a good illustration of our problem with rare catastrophic complications. warmup:  heparin infusions and rare catastrophic complications A […]

Diuretics are a bit like vasopressors.  We use them all the time, so we feel that we know them pretty well.  However, the amount of RCT-level evidence on them is shockingly low.  So, whenever a RCT on diuretics shows up, it’s worth careful examination. the 3T trial:  basics This is a single-center, double-blind trial involving […]

Since finishing my training, I’ve learned three new techniques for the management of hyponatremia:  the DDAVP clamp, use of hypertonic bicarbonate, and oral urea.  Meanwhile, I’ve removed the use of vaptans from my practice and grown more comfortable using 3% saline.  The confluence of these factors has transformed hyponatremia from something scary to something which […]

Using hypertonic saline to facilitate diuresis seems counterintuitive, paradoxical even.  Volume overloaded patients have excess sodium.   Why should we give them more?  Let’s start by trying to understand the underlying physiology. hypochloremia may cause renal sodium retention We generally don’t pay much attention to serum chloride levels.  Chloride is often viewed as a leftover, an […]