PulmCrit (EMCrit)

As a medical student I rotated through an elite hospital where it was believed that every patient admitted to the medicine service needed a rectal exam.  The rationale was to avoid ever missing a case of rectal or prostate cancer.  Eventually, the utility of digital rectal examination as a cancer-screening tool was debunked.  Thankfully, this practice has fallen out of … [Read more...]

Example #1:  Osmolar Gap I'm a bit skeptical of the value of screening toxicology patients by measuring an osmolar gap.  So I looked for literature about the test's performance.  Lynd 2008 found that an elevated osmolar gap had a sensitivity of 90% and a specificity of 22% (1).  That's about what I might have guessed - the test is fairly sensitive and very poorly specific (it … [Read more...]

We all want to alleviate pain and suffering.  Most critically ill patients are treated with opioids for this reason.  Unfortunately, opioids have numerous side-effects including delirium, constipation, vomiting, and delayed extubation.  Opioid infusions may eventually lead to withdrawal, causing pain, nausea, and depression.  This post explores the optimal use of systemic … [Read more...]

Prior to extubation, the cuff leak is usually checked.  This consists of deflating the cuff of the endotracheal tube to verify that gas is able to move around the tube.  Absence of a cuff leak suggests the presence of airway edema, increasing the risks of post-extubation stridor and reintubation.  However, the test isn't that great.  Absence of cuff leak can also occur due to … [Read more...]

In 2014 I wrote a post suggesting an aggressive, streamlined approach to status epilepticus involving early intubation.  The fundamentals of that post remain valid.  However, much has changed over the last few years.  This post aims to refresh and extend the prior post.  It will also serve as a reference to explain my algorithm for status epilepticus in the upcoming … [Read more...]