Introduction: Problem of the premature standard of care 0 This issue has previously been discussed with regards to heparin and thrombolysis for submissive pulmonary embolism.  Heparin was adopted as treatment for PE before the era of evidence-based medicine.  Although heparin prevents further clot formation, it probably doesn’t have any immediate effect on hemodynamic stability.  Regardless, […]

Introduction 0 ACE-inhibitor induced angioedema (ACEI-AAG) accounts for about a third of angioedema cases presenting to the emergency department.  ACE inhibitors are increasingly popular, with the new JNC 8 guidelines up-grading them to a first-line drug for hypertension.  Thus, ACEI-AAG may represent a growing problem.  Unfortunately, this is often treated incorrectly, with a medication regimen […]

  0 Introduction 0 Recently point-of-care ultrasonography (POCUS) has risen in prominence within acute care medicine.  It has been shown to provide immediate and critical information about a variety of conditions ranging from nephrolithiasis to pulmonary edema.  However, POCUS is not without its critics, who point out weaknesses including detection of incidental findings (i.e., small […]

0 Introduction: Selecting the best balanced crystalloid 0 About six months ago, Genius General Hospital added Normosol to its formulary.  For those of you not familiar with Normosol, it is produced by Hospira and is essentially a generic version of Plasmalyte by Baxter (table below).   Although most evidence has been obtained with Plasmalyte, this is […]

0 Introduction 0 Last week Scott Weingart discussed a case of a profoundly hypoxemic patient with a failed airway which was salvaged by surgical cricothyrotomy (listen to it here).  Despite successfully resuscitating the patient there was some criticism later that perhaps a cricothyrotomy wasn’t absolutely required.  This reminds me of a case I’ve been planning […]

  0 Introduction  0 Toxic shock syndrome (TSS) is a true resuscitationist’s disease.  It is potentially quite lethal, with many series of streptococcal toxic shock syndrome reporting mortality in the range of 30-50%.  However, recent observational studies suggest that treatment with modern critical care, toxin-suppressive antibiotics, and IVIG may reduce the mortality to 10% (Linner […]

  0 Introduction 0 Toxic shock syndrome (TSS) is critical to recognize because it can be rapidly lethal and yet is usually treatable.   TSS is a relatively new disease, first described in 1978.   The prevalence has increased over the last few decades due to shifts in the circulating strains of Group A streptococcus (Low 2013).  However, […]

  0 [PLEASE NOTE:  For the most complete & updated material on alcohol withdrawal, please see the Internet Book of Critical Care Chapter on this topic here] 0 Introduction 0 Recently the New England Journal published a review article about delirium tremens which is somewhat misguided (see a scathing critique by The Poison Review).  The […]

Introduction: Medicine is stressful.   Humor helps.   Here are some of the funniest medical videos I’ve seen.   If there is a video you love that’s not here, drop it in the comments section. Disclaimer:   These videos are intended only for healthcare professionals with intact senses of humor.   They contain some foul language.  Watch them at your […]

0 Introduction with an example 0 A 60-year-old woman is admitted with septic shock due to pyelonephritis.  Currently she has received two liters of crystalloid.  Her mean arterial pressure is now 55 mm, her pulse is 120 b/m, and she is producing very little urine.  Bedside ultrasound shows that her IVC is completely empty (sometimes […]

0 Introduction 0 Over the last few years, I’ve gone through an almost 180-degree change in my conceptualization of septic shock.  In a perfect world, this would be irrelevant.  Ideally there would be sufficient randomized controlled trials (RCTs) to answer all important questions directly, and my opinions would be irrelevant.  Unfortunately not.  Reconceptualizing the disease […]

Introduction 0 Traditionally it has been thought that during septic shock, renal blood flow decreases leading to pre-renal kidney injury.  This implied that if we could improve the cardiac output and renal blood flow, the kidneys would recover.  Recent research challenges these concepts, with interesting therapeutic implications. 0 New paradigm of microvascular physiology in renal acute kidney […]

  0 Clinical Question 0 An elderly woman presents with renal failure due to severe dehydration from diarrhea.  She has a hyperchloremic acidosis from diarrhea with a chloride of 115 mEq/L, bicarbonate of 15 mEq/L, and a normal anion gap.  During her volume resuscitation, should isotonic bicarbonate be used to correct her hyperchloremic acidosis?  Does […]

Preamble: Movember 0 Movember is an annual event involving growing a mustache during November to raise awareness and funds to support men’s health issues including prostate cancer.  To support Movember, this post is about mustaches… and critical care, of course.  0 Introduction with a Case 0 Once upon a time at Genius General Hospital, there was […]

Introduction with a case 0 Hydro-point on thoracic ultrasound is diagnostic of an intrapleural air-fluid level, which may be caused by hydropneumothorax, hemopneumothorax, or pyopneumothorax.  This has been described in the literature but is not widely appreciated (Volpicelli 2013).  For example, a prominent ultrasound website may have misdiagnosed this.  Before going further, watch the video […]