Most books give bupropion a couple paragraphs, but it arguably deserves its own chapter. With a decrease in the use of tricyclics and increasing use of bupropion XR for depression, bupropion is becoming the most common cause of life-threatening antidepressant overdose. Bupropion has a uniquely dangerous property of blocking gap junctions between cardiomyocytes at high […]
PulmCrit Wee – Prophylactic antibiotics after cardiac arrest?
background Pneumonia after cardiac arrest is problematic for several reasons: Many patients aspirate during cardiac arrest. Patients are intubated and mechanically ventilated, usually with poor mental status – conditions which do not promote secretion clearance. Early diagnosis of pneumonia is impossible for many reasons (inability to measure a fever due to therapeutic temperature monitoring, inability […]
IBCC chapter & cast – Acalculous cholecystitis
Acalculous cholecystitis is a slippery beast. It’s pretty uncommon, lurking among the myriad of sick ICU patients with moderately abnormal gallbladders. It is likely both under-diagonsed and over-diagonsed at various times. Indeed, since surgical cholecystectomy is currently rare, it is frequently unclear whether a patient ever had acalculous cholecystitis! (For example, if a cholecystostomy drain […]
PulmCrit – Correlation confounded by timing: One reason we believe bad therapies are awesome
example 1: anti-emetics Let’s get started with a RCT comparing droperidol versus ondansetron for the treatment of nausea in the emergency department. Meek et. al randomized 144 nauseated patients to receive either droperidol or ondansetron.1 The rates of symptom improvement were indistinguishable (75% vs 80%). So, you might conclude that these drugs are equally efficacious. […]
IBCC chapter & cast – Carbon monoxide poisoning
In the northern hemisphere, Winter is Coming. Folks are firing up their furnaces – some of which may have an inadequate oxygen supply, thereby generating carbon monoxide. Unfortunately, the diagnosis of carbon monoxide poisoning is extremely hard to make, mimicking many different conditions. In particular, carbon monoxide poisoning can mimimic influenza – which is also […]
IBCC chapter & cast: Post-MI complications
Myocardial infarction patients are complex. Unfortunately, this complexity can grow over time. Delayed deterioration in the patient recovering from MI may result from a host of different problems (e.g. medication effect, procedural complications, or merely the natural history of the disease). This chapter explores some problems that we should be on the lookout for in […]
PulmCrit- Metoprolol causes harm in COPD?? Déjà vu all over again
We’ve been all over the road with beta-blockers and COPD. For a long time, there was a belief that beta-blockers were contraindicated in COPD. Eventually that concept fell out of favor. Subsequently, some correlative data suggested that beta-blockers might be beneficial in COPD. This led to the current BLOCK-COPD trial which (spoiler alert) shows that […]
PulmCrit Wee: Do fluid boluses before intubation help? (PREPARE trial)
I’m afraid she will tank after intubation, could you start some fluid? I brought a liter of fluid, just in case the blood pressure falls after intubation. He is decompensating! Run the fluid wide open! We’ve all probably heard and spoken those phrases. Crystalloid is a traditional therapy in efforts to either prevent or mitigate […]
PulmCrit- Commentary on the new pneumonia guidelines using GIFs & some mini-rants
So, the new IDSA guidelines for community acquired pneumonia (CAP) are here. This post will walk us through the guidelines, focusing primarily on issues that relate to critically ill patients. Guidelines can get dull, I’ve added in GIFs to illustrate my feelings about each recommendation & kept things pretty informal. Come for the GIFs, stay […]
IBCC chapter & cast – Methemoglobinemia
Methemoglobinemia is one of my favorite toxicology diagnoses. The diagnosis can often be made at the bedside based on history and physical examination, which is a satisfying bit of detective work. Once the diagnosis is made, patients generally respond promptly to a specific antidote (methylene blue). And this isn’t just a parlor trick – diagnosis […]
PulmCrit- Tranexamic acid for traumatic brain injury (CRASH3)
preamble CRASH-3 is the latest massive, pragmatic multi-center RCT brought to us by the London School of Hygiene and Tropical Medicine Trials Unit. These investigators have created an extensive network of hospitals throughout the world with the capability of performing truly impressive trials. Especially in the critical care arena, these trials have uniquely high power […]
IBCC asthma chapter post-publication peer review by Weingart
Sometimes muggles criticize FOAM as lacking peer review, but that simply reflects a misunderstanding of the way peer review works here. FOAMed operates off a post-publication peer review system. This typically occurs mostly in the comments section of each blog or chapter (with some on twitter as well). Unlike journals, anyone is free to leave […]
IBCC chapter & cast – Diffuse alveolar hemorrhage & ANCA vasculitis
Diffuse alveolar hemorrhage is encountered uncommonly, but it is useful to have a general understanding of this. Many etiologies can cause diffuse alveolar hemorrhage, with pulmonary vasculitis being perhaps the most widely feared. This chapter explores how to sift through the differential diagnosis of diffuse alveolar hemorrhage and, if vasculitis is suspected, how to initiate […]
IBCC chapter & cast – Asthma
Severe asthma is a challenging topic, because this spans a lot of different patient phenotypes with varying severity and physiology. This chapter attempts to outline some general principles to guide management, but ultimately clinical judgement and serial evaluation at the bedside will trump all of this. The rarity, acuity, and heterogeneity of severe asthma make […]
PulmCrit- Hypothermia for non-shockable arrest: let’s not get hot-headed about this
background Fever is harmful in post-arrest patients. This creates confusion in studies of hypothermia in post-arrest patients: is the benefit of hypothermia due to fever avoidance, due to a benefit from hypothermia itself, or perhaps due to both? Seminal studies in the early 2000s found mortality benefit from application of hypothermia to 33C after cardiac […]
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