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. […]

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 […]

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 […]

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 […]

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 […]

[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 […]

A few weekends ago during a very chaotic call, my ICU team ordered half-dose alteplase for a patient with a submassive PE without checking his INR.   They had performed a thoughtful interview of the patient to look for contraindications to thrombolysis, but somehow this slipped through the cracks.   On reviewing all the data together […]

0 Clinical Question 0 A patient is admitted status post ischemic stroke with focal edema on CT scan.   There is no concern regarding herniation.   Is there a role for continuous infusion of hypertonic saline with a goal of maintaining a sustained elevation of sodium? 0 Theoretical Benefit 0 Theoretically, elevating the tonicity of the blood […]

0 Introduction with a case 0 A otherwise healthy 70 year-old woman presented to Genius General Hospital with multifocal pneumonia.  In the ED she was treated with appropriate antibiotics and two liters of crystalloid.   During her ED course she was found to have increasing tachypnea to 30-35 breaths/min, and was subsequently transferred to the ICU.   […]

Introduction 0 It’s common for critically ill patients to be screened for MI using troponin.   Troponin levels are often positive.   One thing leads to another, and before you know it the frail 99-year-old lady you admitted for a COPD exacerbation has an intracranial hemorrhage from the heparin drip she was put on because her troponin […]

Introduction I have a confession to make: I love treating DKA.   It’s satisfying to take a patient from severe acidosis, electrolytic disarray, and hypovolemia to normal physiology during an ICU shift.   Although it’s usually straightforward, there are some pitfalls and a few tricks that may help your patients improve faster.0 Pearl #1: Avoid normal saline […]

0 PART 1:  Fluid selection for resuscitation of hypovolemic, hyperkalemic renal failure 0 Introduction with a case 0 An elderly man on an ACE inhibitor and NSAIDs presents to the emergency department after a few days of severe norovirus gastroenteritis with a creatinine of 5 mg/dL, a bicarbonate of 15 mEq/L, and a potassium of […]

Introduction 0 Submassive PE can be challenging. Most patients do fine with heparin, but occasional patients suddenly arrest and others are left with longstanding pulmonary hypertension.1 Thrombolytics generally cause dramatic improvement, but may cause hemorrhage as well. Recent studies may seem to point in opposite directions. 0 Background: Heparin vs. Alteplase 0 Treatment centers around […]