EMCrit Project

⚠️AN UPDATE ON THIS TECHNIQUE WAS POSTED IN 2024 HERE.  Introduction 0 Noninvasive ventilation (i.e. BiPAP) is arguably the most powerful approach to optimize oxygenation and ventilation before intubation, given its ability to provide 100% FiO2, PEEP, and ventilatory support.  The only way to improve upon this is to extend the administration of positive pressure […]

Introduction 0 Until recently, recommendations regarding IVC filters have been based predominantly on a singleRCT (PREPIC-1).  Last week, a second RCT was released in JAMA (PREPIC-2).  This post will review both studies.  What is the evidence basis for using IVC filters? 0 PREPIC-1 (Decousus et al.  A clinical trial of vena caval filters in the […]

0 0 Introduction 0 Recently there has been increased interest in the use of high-flow nasal cannula (HFNC) to provide preoxygenation and apneic oxygenation during endotracheal intubation.  Previous posts have discussed the basic physiology and some evidence behind this.  Vourc’h et al. just published a RCT showing no benefit from HFNC in this situation (1).  […]

Introduction 0 The limitations of p-values for null hypothesis testing has been debated since their invention in the 1920s.  Unfortunately, statistics textbooks typically whitewash this controversy, presenting null hypothesis testing as the only viable approach to statistics.  Recently, the journal of Basic and Applied Social Psychology took this debate a step further, officially banning the […]

0 Introduction 0 Recently an excellent post on the Trauma Professional’s Blog pointed out that nocturnal vital signs disrupt sleep and may be unnecessary in stable patients (e.g. patients recovering from minor orthopedic surgery).  I couldn’t agree more.  Allowing restorative sleep is one of the best approaches to prevention of delirium. 0 What about patients […]

Introduction 0 Gastrointestinal hemorrhage is a common reason for ICU admission.  The approach to severe upper GI bleeding is relatively straightforward (figure below).  A predictable approach facilitates planning ahead, and anticipating who needs to be contacted for help when.  0 0 Unfortunately, the approach to severe hematochezia is often less clear.  Below is a description […]

Introduction 0 In April 2013 a series of articles in Radiology debated whether contrast nephropathy still exists using modern contrast dye.  Two years later, the controversy remains.  This is a daily conundrum when managing critically ill patients: one radiologist will urge us to use contrast, while the next radiologist will caution us against using contrast. […]

0 Introduction 0 There is increasing recognition that sodium polystyrene sulfonate (Kayexalate) is ineffective for the immediate management of severe hyperkalemia (Kamel 2012).  With Kayexalate gone, there seems to be a gap in our treatment regimen.  I often encounter residents who know that Kayexalate isn’t helpful, but aren’t sure exactly how to treat hyperkalemia without […]

0 Introduction 0 Last summer I wrote a postabout preoxygenation and apneic oxygenation using high-flow nasal cannula (HFNC).  At that point there was no evidence supporting it, so the post was based primarily on the physiology of HFNC.  Recently two papers were published supporting the use of HFNC for preoxygenation and apneic oxygenation (Patel 2015, […]

  0 0 Introduction with a case 0 A 75-year-old man presents in transfer to the ICU for management of bradycardia and hyperkalemia.  His history is notable for hypertension with chronic use of an ACE-inhibitor.  He developed gastroenteritis due to endemic Norovirus some days prior.  Today he presented to the outside hospital with hypotension and […]

0 Introduction 0 Guillain-Barre Syndrome (GBS) and Myasthenia Gravis (MG) are common causes of acute weakness.  About 25% of these patients may develop respiratory failure requiring intubation, so a major concern is determining who requires ICU-level monitoring and whether intubation should be performed.  Ideally it would be possible to predict with 100% accuracy which patients […]

Introduction: Problem of the premature standard of care 0 This issue has previously been discussed with regards to heparin and thrombolysis for submissive pulmonary embolism.  Heparin was adopted as treatment for PE before the era of evidence-based medicine.  Although heparin prevents further clot formation, it probably doesn’t have any immediate effect on hemodynamic stability.  Regardless, […]

Introduction 0 ACE-inhibitor induced angioedema (ACEI-AAG) accounts for about a third of angioedema cases presenting to the emergency department.  ACE inhibitors are increasingly popular, with the new JNC 8 guidelines up-grading them to a first-line drug for hypertension.  Thus, ACEI-AAG may represent a growing problem.  Unfortunately, this is often treated incorrectly, with a medication regimen […]

  0 Introduction 0 Recently point-of-care ultrasonography (POCUS) has risen in prominence within acute care medicine.  It has been shown to provide immediate and critical information about a variety of conditions ranging from nephrolithiasis to pulmonary edema.  However, POCUS is not without its critics, who point out weaknesses including detection of incidental findings (i.e., small […]