Today, a discussion of 10 heuristics for the New ICU (or Resus) Attending
Ross Prager, MD
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Ten cognitive check points (general rules or heuristics to help guide my practice) I use in the ICU to help make sure I don't get too far off track. A thread🧵👇
1. POCUS for narrow pulse pressure shock
Shock with a narrow pulse pressure (<30mmHg) needs an urgent #POCUS (or echo) to identify occult RV/LV failure, obstructive shock, or severe hypovolemia.
2. Persistent hypovolemia = possible dynamic LVOTo
3. Nurse asking same question twice
4. Septic shock does not equal distributive shock
5. sepsis NYD should rarely be a diagnosis in the ICU
Be wary of admitting a patient to the ICU with a diagnosis of sepsis NYD (not yet diagnosed)- in the ICU, we should be able to figure out the D (diagnosis). Repeat the primary history, re-examine, consider pan-CT, echo, focused TEE etc. Think about where infection can hide! (valves, belly, heart etc.)
6. Elevated lactate does not mean fluid
7. No such thing as a stable post arrest patient
8. Cardiac arrest patients are simultaneously: neuro, trauma, and cardiac patients
Post cardiac arrest pts. are simultaneously a 1) cardiac patient (their heart stopped) 2) neuro patient (we care about their brain) 3) and trauma patient (someone just crushed their chest for like 30 min).
If you are CT scanning post arrest, low threshold to PAN scan (head, chest, abdo)
Also, if you are going to order a CT chest, consider a PE protocol so you never have to discuss on rounds whether the patient could have an occult PE as the etiology arrest!!! 🫀🧠🦴
9. if POCUS is telling you to give more fluids, you are probably using it wrong
10. When a family or patient says they want everything done, it is rarely life at all cost but rather that they don't want you to give up on them
If a pt or family says they want everything done – clarify this!!!
When you dive into it, it often means not giving up on them. They want you to try to diagnosis them, correct treatable causes, and if they are dying, provide them a comfortable and dignified death.
Rarely is it life at all cost or indefinite prolongation of dying with life support.
Additional New Information
More on EMCrit
Additional Resources
- EMCrit 394 – CV-EMCrit – Inotrope Basics Part 2 – Specific Scenarios - February 7, 2025
- EMCrit RACC-Lit – January 2025 - February 4, 2025
- EMCrit 393 – CV-EMCrit – Inotrope Basics Part 1 - January 25, 2025
these are great. Especially #10. Patients are more complicated than what neatly fits into the “code status” order. at least 50% of the time when I have a “do not intubate” patient, when I dive into it they are fully OK with temporarily being intubated for a likely reversible dx. If you are having code status convos that last less than 15 minutes, you are probably not doing it right.
GREAT episode.
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Useful article, very detailed analysis helps me better understand the general rules or heuristics when used in the ICU. Use caution when admitting a patient to the ICU with a diagnosis of NYD sepsis foodle.