PulmCrit (EMCrit)

Calcium channel blocker poisoning is one of the most formidable intoxications encountered critical care.  As for most topics in toxicology, there is no level-I evidence regarding this.  This chapter explores treatment options for beta blocker and calcium channel blocker poisoning, with the admitted limitation that it’s impossible to know which treatments are optimal and in […]

Let’s be honest, necrotizing fasciitis is a perennial source of errors.  This is a difficult diagnosis to make.  It can be tedious to continually maintain a high level of suspicion for it, but suspicion and early diagnosis are critical. The IBCC chapter is located 👉 here. The podcast & comments are below. Follow us on […]

Sympathomimetic intoxication is increasingly common (e.g., with increasing use of methamphetamine).  Although this is a classic topic in toxicology, recent controversy has surrounded the optimal therapy for acute intoxication (benzodiazepines vs. antipsychotics).  This chapter will attempt to provide a general approach to sympathomimetics, recognizing that in many cases it may be impossible to determine precisely […]

Malignant hyperthermia is a rare diagnosis, but nonetheless one worth being aware of.  Very rarely, malignant hyperthermia may be triggered by succinylcholine, causing it to present initially in the emergency department or ICU.  Far more often, malignant hyperthermia will be diagnosed in the operating room – with intensivists involved in providing follow-up care. The IBCC […]

We obtain coagulation labs on nearly every critically ill patient.  However, our understanding of these labs remains relatively superficial.  Meanwhile, the addition of thromboelastography (TEG) has rendered matters even more complex, by providing an alternative strategy for monitoring coagulation.  This chapter attempts to sift through a rational approach to coagulation labs, but much work remains […]

We are seeing an increased volume of alcoholic liver disease due to the COVID pandemic.  Previously admissions to ICU for alcoholic hepatitis were rare, but these are now occurring with regularity. The IBCC chapter is located 👉 here. The podcast & comments are below. Follow us on iTunes

Stupor and coma can be a challenging presentation, because it has a broad differential filled with very severe diseases.  An organized approach is essential.  One core feature of that approach is the coma neurologic examination, which remains central to the evaluation even in the era of abundant CT and MRI scanning. The IBCC chapter is […]

COVID will eventually lead to many improvements in our approach to critical illness.  I’ve been hoping that one of these would be an improved understanding of venous thromboembolism (VTE) prophylaxis, but perhaps that was overly optimistic. We provide VTE prophylaxis to nearly every patient in the ICU.  Consequently, even tiny changes in our VTE prophylaxis […]

Acute Eosinophilic Pneumonia is rare, but it definitely happens.  It typically causes relatively rapid-onset ARDS, frequently leading to mechanical ventilation.  Prompt recognition is critical, because AEP responds beautifully tosteroid therapy. The IBCC chapter is located 👉 here. The podcast & comments are below. Follow us on iTunes  

Acute on Chronic Liver Failure (ACLF) refers to decompensated cirrhosis causing failure of at least two organs (e.g. hepatic encephalopathy, hepatorenal syndrome, shock, or respiratory failure).  It may be useful to conceptualize these patients as having ACLF (rather than, for example, hepatic encephalopathy plus hepatorenal syndrome), because this provides a more accurate global understanding of […]

A fresh preprint reveals the results of combining three trials to evaluate therapeutic anticoagulation among severe COVID patients (defined as patients requiring high flow nasal cannula, noninvasive ventilation, intubation, vasopressors, or inotropes).  Patients were randomized to therapeutic anticoagulation versus thromboprophylaxis per usual care guidelines.  REMAP-CAP also simultaneously randomized some patients to receive aspirin as well.  […]

Convalescent plasma use against epidemic respiratory viruses dates back to the influenza pandemic of 1918.  This intervention has persisted for over a century based on high face-validity, rather than any high-quality evidence.  The COVID epidemic reignited enthusiasm for this therapy, leading to its use in tens of thousands of patients (e.g., an expanded-use program organized […]

Acute liver failure is rare, but when it does occur it requires an organized diagnostic and therapeutic approach.  Success often relies upon aggressive support of other organs (e.g. renal failure and management of intracranial hypertension). The IBCC chapter is located 👉 here. The podcast & comments are below. Follow us on iTunes

Spontaneous bacterial peritonitis is an important consideration for any hospitalized patient with substantial ascites.  Patients can have minimal symptoms.  To complicate matters further, in some cases spontaneous bacterial peritonitis may present with failure of other organs (e.g. hepatic encephalopathy, or disseminated intravascular coagulation leading to gastrointestinal hemorrhage). The IBCC chapter is located 👉 here. The […]

Invasive candidiasis is growing more common in the ICU, as our patients are becoming increasingly complex, with longer stays.  However, most isolation of Candida in the ICU represents colonization rather than infection – so there is a major risk of overdiagnosis resulting in unnecessary medication toxicity and antimicrobial resistance. The IBCC chapter is located 👉 here. […]