EMCrit Project

The closed mouth catches no flies Benjamin Franklin, Poor Richard’s Almanac, 1742 We’re hopefully nearing the end of the COVID pandemic, with vaccines coming soon.  Unfortunately, vaccines won’t be able to bail us out this winter.  Neither will fancy designer pharmaceuticals.  The main interventions necessary to keep us safe for now are basic public health […]

2020 has been a weird year by any standard.  So, I shouldn’t be surprised that the bamlanivimab story is so weird.  But still.  Anyhow, if you’re ready to go down the rabbit hole, here we go… derivation and early testing The story begins with Eli Lilly designing a monoclonal anti-spike antibody to neutralize COVID-19. The […]

We are continually tasked with triaging COVID patients, a situation which will become more complex as the numbers continue to rise.  This involves making educated guesses about which patients are most likely to deteriorate, and which patients may benefit most from critical care.  That’s enormously difficult. At this point, we’re quite familiar with individual risk […]

background:  what is heparin resistance? Heparin works by binding to antithrombin III and thereby activating antithrombin III, an endogenous anticoagulant which inhibits clotting factors (especially Xa).  Heparin + Anti-thrombin III → [Heparin-Antithrombin-III complex] → Inhibition of Xa activity Heparin resistance refers to situations where unusually large doses of heparin are required to achieve anticoagulation.  This […]

When I saw the infographic for the DAMASK trial (below), it was immediately clear to me that the trial was inconclusive (not positive, not negative – inconclusive). According to this study, masks might be totally worthless. Or masks might reduce infection by ~40%. This is an inconclusive study. It yields no answer.

Not all septic shock is created equal.  Toxic shock syndrome is one of the most fulminant and dangerous forms of septic shock.  It is one of the few infectious diseases capable of rapidly killing previously healthy young people.  Most importantly, toxic shock syndrome requires targeted therapy – it often fails to respond to conventional therapy […]

VAP is a perennial riddle in the intensive care unit.  There are numerous murky diagnostic tests, but no single gold-standard diagnostic test.  Consequently, we are usually left wondering whether or not the patient truly has a VAP.  This makes VAP an unsatisfying diagnosis, as we are continually walking a blurred line between undertreatment and overtreatment. […]

Sedation is one of the details of ICU care which seems unimportant…  until it’s not.  Over the past decade we’ve seen a burgeoning repertoire of agents used for sedation and agitated delirium.  Unfortunately, the number of medications has out-stripped available Level-I evidence regarding how exactly to use them.  This chapter attempts to create a framework […]

Lithium intoxication is a tricky issue, with a variety of different forms which may call for different therapies (acute, chronic, or acute-on-chronic intoxication).  To further complicate matters, the pathophysiology of lithium toxicity isn’t understood – particularly, how lithium levels might relate to chronic neurotoxicity (SILENT syndrome).  Finally, as is often the case in toxicology, there […]

Glycemic control in the ICU is a topic of perpetual controversy.  We’ve come full circle in the past 20 years – beginning with permissive hyperglycemia, then moving to tight control, and finally now moving back to permissive hyperglycemia.  The final answer remains unknown, but in the interim this chapter attempts to muddle through available evidence. […]

Wernicke encephalopathy is important because it’s surprisingly common, potentially debilitating, and fully treatable.  Some patients may present to the hospital due to Wernicke encephalopathy, while many others may develop this while in the ICU as an iatrogenic complication of criical care. The IBCC chapter is located 👉 here. The podcast & comments are below. Follow […]

Valproic acid poisoning is fortunately uncommon.  However, this is a potentially lethal and rather complex intoxication.  Management spans the gamut from decontamination and dialysis, to various metabolic manipulations.  With an aggressive and organized approach, most patients will do extremely well. The IBCC chapter is located 👉 here. The podcast & comments are below. Follow us […]

BRASH syndrome refers to a vicious spiral wherein hyperkalemia and AV nodal blockers synergize to cause progressive renal failure, bradycardia, shock, and hyperkalemia.  The treatment is largely a combination of standard therapies for hyperkalemia and bradycardia.  Recognizing this syndrome as a specific entity may help us more fully understand our patients’ physiology, facilitating a more […]

Intensivists have long been struggling with the enigma of hemophagocytic lymphohistiocytosis (HLH).  For example, this post from 2016 explores the challenge of dissecting HLH away from septic shock.  The COVID pandemic has drawn some attention to the topic, although it’s not clear to what extent COVID might truly reflect HLH.  This chapter attempts to lay […]

Critical illness leads to a variety of gastrointestinal motility problems (largely due to the constellation of immobility, medications, and metabolic abnormalities).  Although these topics don’t generally attract much interest, maintaining adequate bowel motility is essential to avoid iatrogenic harm. The chapter on gastroparesis is located 👉 here. The chapter on ileus is located 👉 here. […]