EMCrit Project https://emcrit.org Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Fri, 22 Feb 2019 15:48:08 +0000 en-US hourly 1 https://wordpress.org/?v=5.0.3 https://emcrit.org/feed/podcast/ Help me fill in the blanks of the practice of ED Critical Care. In this podcast, we discuss all things related to the crashing, critically ill patient in the Emergency Department. Find the show notes at emcrit.org. Scott D. Weingart, MD FCCM clean episodic Scott D. Weingart, MD FCCM spambin55@gmail.com spambin55@gmail.com (Scott D. Weingart, MD FCCM) 2009- Online Medical Education on Emergency Department (ED) Critical Care, Trauma, & Resuscitation EMCrit Project http://emcrit.org/wp-content/uploads/powerpress/3000x3000-emcrit.jpg https://emcrit.org/category/pulmcrit/ IBCC chapter & cast: Hypernatremia https://emcrit.org/pulmcrit/hypernatremia-2/ https://emcrit.org/pulmcrit/hypernatremia-2/#comments Thu, 21 Feb 2019 12:26:27 +0000 https://emcrit.org/?p=460019 Treating hypernatremia in the ICU isn't exciting or particularly difficult.  However, it's enormously important to provide patients with comfort.  We talk a lot on treating pain, but usually forget about the discomfort caused by thirst.  Remember:  when you intubate a patient and take control of their airway, you're also taking responsibility to provide them with water.

EMCrit Project by Josh Farkas.

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PulmCrit: Is pure RSI a failed paradigm in critical illness? The primacy of pressure https://emcrit.org/pulmcrit/pressure-rsi/ https://emcrit.org/pulmcrit/pressure-rsi/#comments Tue, 19 Feb 2019 13:12:16 +0000 https://emcrit.org/?p=459880 Why do some patients' saturation crash during laryngoscopy, whereas other patients are fine?  What can we do to prevent this?

EMCrit Project by Josh Farkas.

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IBCC chapter: Salicylate intoxication https://emcrit.org/pulmcrit/salicylates/ https://emcrit.org/pulmcrit/salicylates/#respond Thu, 14 Feb 2019 11:45:37 +0000 http://emcrit.org/?p=459801 Of all intoxications, salicylates is one of the most important to understand.  These cases can unravel rapidly, with fatal outcome.  However, with prompt management most patients will do fine.  Treatment depends on a solid grasp of the underlying chemistry and renal physiology.

EMCrit Project by Josh Farkas.

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PulmCrit: The surviving sepsis campaign 1-hour bundle is… back? https://emcrit.org/pulmcrit/ssc-1-hour/ https://emcrit.org/pulmcrit/ssc-1-hour/#comments Tue, 12 Feb 2019 11:47:21 +0000 http://emcrit.org/?p=459475 The surviving sepsis campaign (SSC) has had substantial problems dating back to its inception.  The original backbone of the guidelines was a single-center trial by Rivers, which has largely been debunked.1–4  Initially the SSC was slow to let go of invasive early goal-directed therapy.  The SSC has finally started eliminating older dogma (e.g., superior vena cava […]

EMCrit Project by Josh Farkas.

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IBCC chapter: Buprenorphine & opioid use disorder https://emcrit.org/pulmcrit/buprenorphine/ https://emcrit.org/pulmcrit/buprenorphine/#respond Mon, 11 Feb 2019 11:45:50 +0000 http://emcrit.org/?p=459692 In critical care, we’ve been treating patients with opioid use disorder for a long time.  If they’re intubated for intoxication, we extubate them and send them home.  If they’re septic with endocarditis, we treat their sepsis.  Unfortunately, this isn’t enough.  We’re treating the complications of opioid use disorder, without addressing the underlying problem. Recently, medication-assisted […]

EMCrit Project by Josh Farkas.

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IBCC chapter: Thyroid storm https://emcrit.org/pulmcrit/thyroid-storm-2/ https://emcrit.org/pulmcrit/thyroid-storm-2/#comments Thu, 07 Feb 2019 12:33:37 +0000 http://emcrit.org/?p=459525 Thyroid storm is a bit of a zebra.  It can mimic a variety of common conditions (e.g. sepsis, delirium, heart failure).  Unfortunately, if you're not looking for it, you probably won't find it.   Once identified, an organized multimodal treatment regimen will generally get the job done.  But be careful - these patients may have varying physiology, so blindly following the same rubric for every single patient isn't the answer.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: thrombocytopenia & HITT https://emcrit.org/pulmcrit/thrombocytopenia/ https://emcrit.org/pulmcrit/thrombocytopenia/#comments Thu, 31 Jan 2019 11:11:45 +0000 http://emcrit.org/?p=459418 Thrombocytopenia is extremely common in critical illness.  It's generally a consequence rather than a cause of illness, predicting increased mortality.  However, we must remain alert for cases where serious hematologic disease is afoot.  The major concern here is the ever-looming possibility of heparin-induced thrombocytopenia and thrombosis (HITT).  This chapter explores thrombocytopenia and provides an evidence-based […]

EMCrit Project by Josh Farkas.

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PulmCrit- Inhaled NO for submassive PE: iNOPE or iYEP? https://emcrit.org/pulmcrit/inope/ https://emcrit.org/pulmcrit/inope/#comments Mon, 28 Jan 2019 11:47:08 +0000 http://emcrit.org/?p=459337 The use of an inhaled pulmonary vasodilator is a logical strategy for stabilization of PE patients (especially nitric oxide, which may be depleted in this situation). Previously inhaled nitric oxide has only been supported by case series.

EMCrit Project by Josh Farkas.

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IBCC chapter: Antibiotics for the critically ill patient https://emcrit.org/pulmcrit/antibiotics/ https://emcrit.org/pulmcrit/antibiotics/#comments Thu, 24 Jan 2019 14:25:34 +0000 http://emcrit.org/?p=459313 We spend a lot of time obsessing over the finer details of critical care:  which fluid is best?  which vasopressor is best?  will another liter of fluid help?  These details are important, but for a septic patient something more important than any of these details is choosing the right antibiotic(s).  In septic shock, source control and […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Undifferentiated shock https://emcrit.org/pulmcrit/shock/ https://emcrit.org/pulmcrit/shock/#comments Thu, 17 Jan 2019 15:06:03 +0000 http://emcrit.org/?p=458596 Shock is the next-door neighbor of death.  Shock can present in a myriad of different forms, making early recognition challenging.  However, early diagnosis is essential.  Shock can be caused by a broad differential of serious illnesses.  Unlike most differential diagnosis lists, every item on this differential is life-threatening.  Fortunately, many causes of shock are reversible […]

EMCrit Project by Josh Farkas.

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PulmCrit- Vancomycin pharmacokinetics: Make vanco great again https://emcrit.org/pulmcrit/vanco/ https://emcrit.org/pulmcrit/vanco/#comments Wed, 16 Jan 2019 14:36:22 +0000 http://emcrit.org/?p=457864 Traditionally, vancomycin doses have been adjusted to target a specific trough level.  However, it is increasingly clear that the trough level is an inadequate measurement of vancomycin exposure.  Furthermore, the practice of waiting until the fourth dose to measure the trough level may expose the patient to days of suboptimal therapy.

EMCrit Project by Josh Farkas.

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PulmCrit- Acute infection & myocardial infarction: How afraid should we be? https://emcrit.org/pulmcrit/infection-mi/ https://emcrit.org/pulmcrit/infection-mi/#comments Mon, 14 Jan 2019 13:19:48 +0000 http://emcrit.org/?p=457465 Occasionally, the NEJM publishes a scary article that gets a lot of press, but doesn’t pan out to be valid.  The recent example is the PESIT study, which seemed to imply that everyone admitted with syncope had PE (don’t worry- they don’t). It looks like NEJM might be at it again, with this week’s review article on the relationship between acute infection and MI.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Severe influenza https://emcrit.org/pulmcrit/influenza/ https://emcrit.org/pulmcrit/influenza/#comments Thu, 10 Jan 2019 14:24:29 +0000 http://emcrit.org/?p=456787 Initially I wasn't planning to write a chapter on influenza, because there is precious little evidence regarding ICU management.  However, even in the absence of solid evidence, we will be called upon to treat these patients.  Currently flu season is afoot, and it looks like it might be a bad one (with a predominance of […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Acute Kidney Injury https://emcrit.org/pulmcrit/acute-kidney-injury/ https://emcrit.org/pulmcrit/acute-kidney-injury/#comments Wed, 02 Jan 2019 20:51:07 +0000 http://emcrit.org/?p=456607 The importance of avoiding and treating renal failure cannot be overstated.  The kidneys are delicate organs, often the first to be injured by systemic hypoperfusion or other insults.  Severe renal dysfunction leads to a cascade of badness, promoting the failure of other organs and eventual spiraling into multi-organ failure.1  Alternatively, if we are can defend […]

EMCrit Project by Josh Farkas.

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PulmCrit- Antibiotics for abscesses, white walkers, and the inherent myopia of science https://emcrit.org/pulmcrit/antibiotics-abscess/ https://emcrit.org/pulmcrit/antibiotics-abscess/#comments Mon, 31 Dec 2018 11:00:04 +0000 http://emcrit.org/?p=456500 There are a number of reasons that an idea may be impossible to test scientifically.  Perhaps the disease state that the idea applies to is extremely rare.  Perhaps it is logistically impossible to test the idea, due to issues with blinding or time constraints.  This post will focus on an insidious reason that ideas are thrown beyond the wall:  the timeframe and study size required to test them are unachievable.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Community-acquired urosepsis https://emcrit.org/pulmcrit/urosepsis/ https://emcrit.org/pulmcrit/urosepsis/#comments Wed, 26 Dec 2018 18:21:34 +0000 http://emcrit.org/?p=456381 Urosepsis is one of my favorite ICU diagnoses.  In almost all cases, patients will improve dramatically within 12-24 hours and leave the ICU with minimal sequelae.  But that shouldn't lull us into a false sense of security:  careful antibiotic selection, aggressive resuscitation, and (in some cases) emergent drainage may be required for a good outcome.  

EMCrit Project by Josh Farkas.

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IBCC chapter & cast- Immune-related adverse events from checkpoint inhibitors https://emcrit.org/pulmcrit/checkpoint/ https://emcrit.org/pulmcrit/checkpoint/#respond Wed, 19 Dec 2018 13:40:38 +0000 http://emcrit.org/?p=456183 If you haven't started seeing these yet, you will soon.  Checkpoint inhibitors are a form of immunotherapy being used for an increasingly broad range of malignancies.  They cause a diverse range of adverse events, due to releasing uncontrolled autoimmune hyperactivity.  Clinically this can mimic just about any rheumatologic condition.  Fortunately these events are quite treatable.  However, a high index of suspicion and prompt therapy is important.  

EMCrit Project by Josh Farkas.

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PulmCrit- Rant: Antimicrobial exposure and risk of delirium https://emcrit.org/pulmcrit/antibiotics-delirium/ https://emcrit.org/pulmcrit/antibiotics-delirium/#comments Mon, 17 Dec 2018 13:00:59 +0000 http://emcrit.org/?p=456119 This paper slipped across my twitter feed over the weekend.  It was a bit disquieting to see that it was getting a lot of attention, despite being a methodological train wreck (seriously, MedTwitter, where’s the skepticism??).  This post will briefly walk through some of the main flaws.  There will be a bit of pharmacology, a modicum of methodology, and a lot of ranting.  

EMCrit Project by Josh Farkas.

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IBCC chapter & cast- Adrenal crisis https://emcrit.org/pulmcrit/adrenal-crisis/ https://emcrit.org/pulmcrit/adrenal-crisis/#comments Wed, 12 Dec 2018 13:00:27 +0000 http://emcrit.org/?p=456002 Adrenal crisis is a can't-miss diagnosis.  Prompt identification and proper management will generally lead to rapid improvement.  The most important aspect is maintaining a high index of suspicion.  When in doubt, start empiric therapy first and ask questions later. The IBCC chapter is located here. The podcast & comments are below. Follow us on iTunes

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Post-cardiac arrest management https://emcrit.org/pulmcrit/post-arrest/ https://emcrit.org/pulmcrit/post-arrest/#comments Wed, 05 Dec 2018 14:35:50 +0000 http://emcrit.org/?p=455859 Post-cardiac arrest management has undergone substantial revisions within the past several years, particularly with regards to temperature management.  This remains an area of active controversy and investigation, with the TTM-2 trial currently underway.  Although equipoise still exists, this chapter describes a streamlined 36C approach which is based on evidence, guidelines, and experience with various strategies. […]

EMCrit Project by Josh Farkas.

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PulmCrit- Alpha-2 agonists: clonidine, guanfacine, lofexidine, and KetaDex https://emcrit.org/pulmcrit/ketadex/ https://emcrit.org/pulmcrit/ketadex/#comments Mon, 03 Dec 2018 13:50:06 +0000 http://emcrit.org/?p=455808 Dexmedetomidine is an intravenous alpha-2 agonist used as a sedative infusion.  It has some uniquely useful properties, particularly that it doesn’t suppress respiration (allowing it to be safely used in non-intubated patients).  The main drawbacks of dexmedetomidine are logistic:  it is expensive and can be administered only as an IV infusion within an ED or ICU.  Oral clonidine offers some similar benefits compared to dexmedetomidine, without these logistic constraints.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Meningitis and encephalitis https://emcrit.org/pulmcrit/meningitis-2/ https://emcrit.org/pulmcrit/meningitis-2/#comments Wed, 28 Nov 2018 11:44:48 +0000 http://emcrit.org/?p=455732 Severe CNS infections are a bit of an orphan disease in critical care.  Unlike more common neurologic disorders (e.g. stroke), CNS infections are too rare to recruit lots of patients into RCTs.  Consequently, conventional treatment of these disorders lags decades behind other neurologic disorders (e.g. in terms of optimizing cerebral perfusion pressure).  Principles of neurocritical […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Torsades de Pointes https://emcrit.org/pulmcrit/tdp/ https://emcrit.org/pulmcrit/tdp/#comments Wed, 21 Nov 2018 13:51:08 +0000 http://emcrit.org/?p=455493 Torsades de pointes is an uncommon cause of cardiac arrest.  It is generally quite treatable, but if treated inadequately it will often recur (in some cases leading to repeated salvos of ventricular tachycardia, one form an electrical storm).  A structured approach incorporating a pre-emptive protocoled magnesium infusion is generally quite effective. The IBCC chapter is […]

EMCrit Project by Josh Farkas.

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IBCC: Guide to supportive care in critical illness https://emcrit.org/pulmcrit/guide/ https://emcrit.org/pulmcrit/guide/#comments Mon, 19 Nov 2018 15:10:35 +0000 http://emcrit.org/?p=455440 This chapter gives an overview of how to provide high-quality supportive care to the sickest patients.  It summarizes about a dozen chapters within the IBCC.  This is intended as a quick guide for folks who don't work full-time in an ICU (e.g. residents rotating through the unit).  

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Hyperkalemia https://emcrit.org/pulmcrit/hyperk/ https://emcrit.org/pulmcrit/hyperk/#comments Wed, 14 Nov 2018 11:09:04 +0000 http://emcrit.org/?p=455366 Hyperkalemia is bread and butter critical care medicine.  However, the therapeutic approach has changed substantially within the past 5 years. Myths about kayexalate and normal saline have been exposed, allowing more effective therapies to take their place.  

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Delirium https://emcrit.org/pulmcrit/delirium/ https://emcrit.org/pulmcrit/delirium/#comments Wed, 07 Nov 2018 13:50:19 +0000 http://emcrit.org/?p=455234 Delirium occurs in about half of critically ill patients.  Some fairly simple measures may reduce the risk of delirium.  When it occurs, delirium is a diagnostic challenge because occasionally it can be a sign of undiagnosed underlying illness.  Treatment is challenging, with little evidence to support most of the standard therapies.

EMCrit Project by Josh Farkas.

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PulmCrit: No more antipsychotics for delirium? Not so fast! https://emcrit.org/pulmcrit/antipsychotics-delirium/ https://emcrit.org/pulmcrit/antipsychotics-delirium/#comments Mon, 05 Nov 2018 13:29:14 +0000 http://emcrit.org/?p=455111 Recently the MINDS-USA trial evaluated the use of haloperidol or ziprasidone for delirium in critical illness.  Before jumping into the results of this study, it will help to establish a couple of foundational principles.

EMCrit Project by Josh Farkas.

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PulmCrit- Does the HIGH trial debunk high-flow nasal cannula? https://emcrit.org/pulmcrit/pulmcrit-does-the-high-trial-debunk-high-flow-nasal-cannula/ https://emcrit.org/pulmcrit/pulmcrit-does-the-high-trial-debunk-high-flow-nasal-cannula/#comments Thu, 01 Nov 2018 13:01:45 +0000 http://emcrit.org/?p=455050 High-flow nasal cannula (HFNC) has become popular for the hypoxemic respiratory failure, driven partially by the FLORALI trial.1  Recently, the HIGH trial evaluated the ability of HFNC to reduce mortality among immunocompromised patients with acute hypoxemic respiratory failure.2  HFNC failed to improve mortality or significantly reduce intubation rates. Popular narrative about this trial A common […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Anemia & transfusion targets https://emcrit.org/pulmcrit/transfusion/ https://emcrit.org/pulmcrit/transfusion/#comments Wed, 31 Oct 2018 12:26:30 +0000 http://emcrit.org/?p=455063 Most patients in the ICU will become anemic.  This chapter explores prevention, evaluation, and treatment of anemia in the ICU.  Causes of new-onset anemia in the ICU are distinct from the causes of anemia seen in the outpatient clinic, so the approach should be appropriately tailored to the critical care environment.   

EMCrit Project by Josh Farkas.

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PulmCrit- SUP-ICU: Is pantoprazole the elixir of life? Should it be? https://emcrit.org/pulmcrit/sup-icu/ https://emcrit.org/pulmcrit/sup-icu/#comments Tue, 30 Oct 2018 11:43:13 +0000 http://emcrit.org/?p=455011 SUP-ICU is a massive, modern RCT of stress ulcer prophylaxis (SUP) in the ICU. With 3298 patients, it is larger than many meta-analyses of SUP. Its primary mortality endpoint is deeply flawed.  However, the study still provides a wealth of information about SUP in the ICU.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Acute pancreatitis https://emcrit.org/pulmcrit/pancreatitis/ https://emcrit.org/pulmcrit/pancreatitis/#comments Thu, 25 Oct 2018 19:29:15 +0000 http://emcrit.org/?p=454895 Management of severe pancreatitis has remained in a state of controlled chaos and persistent debate for years (mirroring evolution in our treatment of septic shock).  This confusion shows no signs of abating in the near future.  This chapter explores a reasonable approach to pancreatitis, with the caveat that there is very little evidence available to guide our combat against this challenging foe.  

EMCrit Project by Josh Farkas.

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PulmCrit- Ketamine for alcohol withdrawal? https://emcrit.org/pulmcrit/ketamine-alcohol-withdrawal/ https://emcrit.org/pulmcrit/ketamine-alcohol-withdrawal/#comments Mon, 22 Oct 2018 11:55:42 +0000 http://emcrit.org/?p=454836 Recent publications have explored the role of ketamine in alcohol withdrawal.  Ketamine undoubtedly has some outstanding properties, which make it well suited for  this task.  The challenge is integrating ketamine into a unified, coherent treatment strategy. 

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: severe heart failure & cardiogenic shock https://emcrit.org/pulmcrit/heart-failure/ https://emcrit.org/pulmcrit/heart-failure/#comments Wed, 17 Oct 2018 12:46:00 +0000 http://emcrit.org/?p=454739 Management of severe heart failure and cardiogenic shock is difficult.  There is a notable lack of high-quality evidence regarding the sickest patients.  Treatment strategies validated among more stable patients may not be applicable to the most unstable heart failure patients.   

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Hypoglycemia https://emcrit.org/pulmcrit/hypoglycemia/ https://emcrit.org/pulmcrit/hypoglycemia/#comments Wed, 10 Oct 2018 10:48:25 +0000 http://emcrit.org/?p=454580 Severe hypoglycemia can be scary, especially when the patient isn't responding to front-line therapies (e.g. IV dextrose).  However, some unconventional tools and an organized approach can make this extremely manageable.

EMCrit Project by Josh Farkas.

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PulmCrit- Alcohol Withdrawal: One order to sedate them all https://emcrit.org/pulmcrit/phenobarbital-oks/ https://emcrit.org/pulmcrit/phenobarbital-oks/#comments Mon, 08 Oct 2018 10:47:14 +0000 http://emcrit.org/?p=454508 I should do a formal retrospective cohort study on this, but I don’t have time.  Fortunately, the ICU group at Northshore/Long Island Jewish has done exactly that.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Bradycardia https://emcrit.org/pulmcrit/bradycardia/ https://emcrit.org/pulmcrit/bradycardia/#comments Wed, 03 Oct 2018 13:36:20 +0000 http://emcrit.org/?p=454444 Bradycardia emergencies are uncommon, but these cases can go sideways fast.  An appropriately aggressive approach is needed to avoid cardiac arrest.  Sometimes the answer is as simple as the appropriate epinephrine dose.  

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: community-onset pneumonia https://emcrit.org/pulmcrit/pneumonia/ https://emcrit.org/pulmcrit/pneumonia/#comments Thu, 27 Sep 2018 11:17:14 +0000 http://emcrit.org/?p=454284 Sir William Osler called pneumonia "the captain of the men of death."  Over a century later, pneumonia remains the leading cause of infectious death in the developed world.  

EMCrit Project by Josh Farkas.

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PulmCrit- Solving the OPTALYSE PE riddle: We’re dosing tPA wrong https://emcrit.org/pulmcrit/pulmcrit-solving-the-optalyse-pe-riddle-were-dosing-tpa-wrong/ https://emcrit.org/pulmcrit/pulmcrit-solving-the-optalyse-pe-riddle-were-dosing-tpa-wrong/#comments Mon, 24 Sep 2018 11:00:08 +0000 http://emcrit.org/?p=454138 Occasionally in science we encounter a truly bizarre result.  Our natural inclination is to ignore the bizarre result.  It’s jarring.  It creates cognitive dissonance, challenging our understanding of the world.  However, struggling to understand the bizarre result can reset our perspective.  It’s often the bizarre, unexpected result that changes everything. 

EMCrit Project by Josh Farkas.

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IBCC Chapter & Cast: GI Hemorrhage https://emcrit.org/pulmcrit/gi-hemorrhage/ https://emcrit.org/pulmcrit/gi-hemorrhage/#comments Wed, 19 Sep 2018 11:11:36 +0000 http://emcrit.org/?p=453974 GI bleeding is bread and butter critical care.  However, there are a lot of nuances - especially regarding variceal bleeding and new approaches to hematochezia.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Troponin elevation in non-cardiac critical illness https://emcrit.org/pulmcrit/troponin/ https://emcrit.org/pulmcrit/troponin/#comments Wed, 12 Sep 2018 10:09:46 +0000 http://emcrit.org/?p=453793 How should we evaluate for myocardial ischemia in a critically ill patient admitted for some other problem (e.g. pneumonia)?  What does it mean if their troponin is elevated?

EMCrit Project by Josh Farkas.

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