0 Introduction 0 The benefit of empirically using two antibiotics to cover gram negative bacilli is a perpetual controversy. For patients in septic shock, failure to provide effective initial antimicrobial therapy correlates with increased mortality. Using two drugs may increase the likelihood of an including at least one antibiotic which covers the pathogen. This […]
What does it mean if a patient is “allergic” to haloperidol?
0 Introduction with a case 0 Once upon a time at Genius General Hospital, a 25-year old man was admitted to the ICU for agitation. After exclusion of an acute medical or neurologic process, it became clear that he was suffering from schizophrenia with medication nonadherence. Unfortunately, his electronic medical record indicated that he had […]
The myth of large-volume resuscitation in acute pancreatitis
Introduction 0 Severe pancreatitis causes fluid extravasation from the vasculature, sometimes causing shock. Traditionally this has been managed by administration of large volumes of crystalloid. For example, the 2013 American College of Gastroenterology Guideline recommended providing 250-500 ml/hour of crystalloid for the first 12-24 hours of hospitalization. They recommended targeting fluid resuscitation to achieve dilution […]
The fallacy of time-to-intervention studies
0 Time and tide wait for no intervention – Geoffrey Chaucer 0 We are barraged by time-to-intervention studies (door-to-balloon time, time-to-antibiotics, door-to-needle, etc.). However, it must be kept in mind that these studies are purely correlational in design. Such studies cannot […]
Could estrogen-receptor antagonists treat Ebola?
Disclaimer: In light of the ongoing epidemic this post is intended to spark interest and invoke discussion about unconventional therapies. Introduction It is widely believed that there is no specific therapy for Ebolavirus. However, this is only partially true. Some experimental therapies exist, including convalescent serum and interferon, but the ability to deploy these to […]
Two EKG patterns of pulmonary embolism which mimic MI
Introduction with a case 0 A 45-year old man presented to the hospital with chest pain and dyspnea. His troponin was positive, and EKG showed T-wave inversions in the inferior leads and V1-V4. He was pale, diaphoretic, tachycardic, and borderline hypotensive with a systolic blood pressure ranging from 85-110mm. He was taken urgently for cardiac […]
Secondary Bacterial Peritonitis
0 Introduction with a case 0 A patient with advanced alcoholic cirrhosis presents to the hospital with fever and altered mental status. Examination is notable for abdominal distention with rebound tenderness. Bedside ultrasound reveals a large amount of ascites, which is carefully sampled revealing a cloudy fluid with 15,000 neutrophils/uL and a differential of 90% neutrophils (a […]
High-flow nasal cannula to prevent post-extubation respiratory failure
0 Background: Post-extubation failure and noninvasive ventilation (NIV) 0 Post-extubation respiratory failure requiring re-intubation is a major setback for any critically ill patient. Current evidence mainly involves the pre-emptive use of NIV to reduce post-extubation failure, particularly in hypercapnic COPD patients. However, in practice this is difficult to implement widely. Except for the sickest COPD […]
Eight pearls for the crashing patient with massive PE
0 Introduction 0 Literature on massive PE focuses mostly on how to deal with the clot while less attention is spent on other aspects of management. This post will focus on such aspects, especially hemodynamic resuscitation of massive PE. There is nearly no clinical data, forcing us to extrapolate between limited data, hemodynamic theory, and […]
Preoxygenation & apneic oxygenation using a nasal cannula
0 Starting Point: We do a bad job at preoxygenation 0 We could do better at preoxygenating patients before emergent intubations. In my experience the most commonly used device for preoxygenation is a bag-valve mask, which has many pitfalls. We often accept a poor mask seal in efforts to remain gentle with awake patients. […]
Dexmedetomidine to facilitate noninvasive ventilation
Introduction 0 Noninvasive ventilation (NIV) has recently emerged as a fundamental treatment for patients with acute exacerbation of obstructive lung disease or cardiogenic pulmonary edema, often avoiding intubation. However, some patients have difficulty tolerating this therapy due to anxiety. Dexmedetomidine (PRECEDEX) is an attractive sedative to manage this problem, since it may be titrated and […]
Thrombolysis reduces mortality in submassive PE
Introduction 0 There has been exciting research into submassive PE (a.k.a., intermediate-risk PE) recently with the release of MOPETT, PEITHO, TOPCOAT, and ULTIMA. In a prior blog post I discussed these studies in detail and suggested that our approach to PE is based on tradition rather than evidence. In summary, heparin is viewed as the […]
Cardiogenic shock following cardioversion of atrial flutter
0 Introduction with a case 0 Once upon a time at Genius General Hospital a 63-year-old woman was admitted with lower extremity edema and orthopnea. Her past medical history was unremarkable. She was noted to be in atrial flutter with a heart rate in the 120s and a blood pressure ranging from 100-120 mm systolic. She […]
Errors of commission vs. errors of omission
Introduction 0 I just heard Scott Weingart’s new podcast about errors of omission compared to errors of commission. The podcast was inspired by a patient with aortic dissection and hemopericardium who arrested and died, without any attempt made to drain the pericardium. This raised the question of whether our culture of “do no harm” has […]
Rapid Sequence Termination (RST) of status epilepticus
[PLEASE NOTE: This post has been updated with a new post. If you have time, consider reading them in sequence, starting with this post first] 0 Introduction 0 Status Epilepticus is our favorite neurologic emergency. If managed correctly, patients will often have excellent neurologic outcomes and short ICU stays. Incorrect management increases risk of […]
