EMCrit Project https://emcrit.org Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Thu, 12 Dec 2019 18:51:59 +0000 en-US hourly 1 https://wordpress.org/?v=5.3.1 https://emcrit.org/feed/podcast/ Help me fill in the blanks of the practice of ED Critical Care. In this podcast, we discuss all things related to the crashing, critically ill patient in the Emergency Department. Find the show notes at emcrit.org. Scott D. Weingart, MD FCCM clean episodic Scott D. Weingart, MD FCCM spambin55@gmail.com spambin55@gmail.com (Scott D. Weingart, MD FCCM) 2009- Online Medical Education on Emergency Department (ED) Critical Care, Trauma, & Resuscitation EMCrit Project http://emcrit.org/wp-content/uploads/powerpress/3000x3000-emcrit.jpg https://emcrit.org EMCrit 261 – Thrombolysis during Cardiac Arrest https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/ https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/#comments Thu, 12 Dec 2019 18:50:40 +0000 https://emcrit.org/?p=469590 Who should we thrombolyse during cardiac arrest?

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/feed/ 1 Who should we thrombolyse during cardiac arrest?
Do you administer thrombolytics during cardiac arrest? Or maybe you don't believe in thrombolytics, but are totally down with fibrinolytics during arrest. Who do you administer them to and which one do you use? I give you my own circuitous ramblings on the topic in this episode.
Who Should Get Lysed?



SR/MA

* Wang et al.

RCT Mentioned

* TROICA (19092151)

Studies not Included in that SR/MA




* PEAPETT (27422214) (RebelM Review)
* French Registry Trial (31381884)






What Lytic?



Full Dose Tenecteplase via Manufacturer Recs or 50 mg of Alteplase by IV Push over ~60 seconds (29880524)





How Long Should You Keep Going?








* 30-60 minutes after lytic administration

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Thanks again!Fred and JF

Now on to the Podcast...


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Scott D. Weingart, MD FCCM clean 21:59
IBCC chapter & cast – Hyponatremia https://emcrit.org/pulmcrit/hyponatremia-2/ https://emcrit.org/pulmcrit/hyponatremia-2/#comments Thu, 12 Dec 2019 13:25:39 +0000 https://emcrit.org/?p=469581 Since finishing my training, I've learned three new techniques for the management of hyponatremia:  the DDAVP clamp, use of hypertonic bicarbonate, and oral urea.  Meanwhile, I've removed the use of vaptans from my practice and grown more comfortable using 3% saline.  The confluence of these factors has transformed hyponatremia from something scary to something which […]

EMCrit Project by Josh Farkas.

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Tox and Hound – Don’t Be A Goofball https://emcrit.org/toxhound/goofball/ https://emcrit.org/toxhound/goofball/#comments Tue, 10 Dec 2019 17:48:28 +0000 https://emcrit.org/?p=469513 by Dan Rusyniak No doubt the plateau in opioid deaths in many towns across America has led to a collective sigh of relief. And to be sure, fewer people dying is a very good thing. But, like the game Whac-A-Mole™, as soon as one epidemic decreases, another emerges. In the mid ’90s to the early […]

EMCrit Project by Tox & Hound.

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PulmCrit- Hyperdiuresis: Using hypertonic saline to facilitate diuresis https://emcrit.org/pulmcrit/pulmcrit-hyperdiuresis-using-hypertonic-saline-to-facilitate-diuresis/ https://emcrit.org/pulmcrit/pulmcrit-hyperdiuresis-using-hypertonic-saline-to-facilitate-diuresis/#comments Mon, 09 Dec 2019 12:35:19 +0000 https://emcrit.org/?p=469434 Using hypertonic saline to facilitate diuresis seems counterintuitive, paradoxical even.  Volume overloaded patients have excess sodium.   Why should we give them more?  Let’s start by trying to understand the underlying physiology. hypochloremia may cause renal sodium retention We generally don’t pay much attention to serum chloride levels.  Chloride is often viewed as a leftover, an […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Hypokalemia https://emcrit.org/pulmcrit/hypokalemia-2/ https://emcrit.org/pulmcrit/hypokalemia-2/#comments Thu, 05 Dec 2019 14:00:30 +0000 https://emcrit.org/?p=469388 Hypokalemia is one of the most commonly encountered electrolyte abnormalities in critically ill patients, and perhaps the most commonly intervened upon abnormality.  Although this is mundane, it behooves us to understand it fully and treat it optimally.  Even minor nuances in treatment could potentially have significant impact, given how commonly hypokalemia is managed. The IBCC […]

EMCrit Project by Josh Farkas.

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Tox and Hound – We Need to Talk About Charcoal https://emcrit.org/toxhound/charcoal/ https://emcrit.org/toxhound/charcoal/#comments Mon, 02 Dec 2019 15:51:53 +0000 https://emcrit.org/?p=469324 by David Juurlink We need to talk about activated charcoal. Why? Because we sometimes give it when we probably shouldn’t, and we sometimes don’t when we probably should. I’ll explain what I mean by this. But first, some background. What is activated charcoal? Activated charcoal (AC) is a gritty black substance that, when administered to […]

EMCrit Project by Tox & Hound.

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EMCrit 260 – Thoughts on the NEJM Acute Upper Airway Obstruction Review https://emcrit.org/emcrit/upper-airway-obstruction/ https://emcrit.org/emcrit/upper-airway-obstruction/#comments Sat, 30 Nov 2019 21:40:57 +0000 https://emcrit.org/?p=469242 Thoughts on a recent NEJM review on upper airway obstruction

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/upper-airway-obstruction/feed/ 1 Thoughts on a recent NEJM review on upper airway obstruction
NEJM recently published an interesting review article on upper airway obstruction. This podcast was spurred by a rantorial on twitter by Farkas regarding the article:

https://twitter.com/PulmCrit/status/1195103809745440768?s=20

I took a look--and it was indeed bad...
Here is the Article:
Eskander et al. Acute Upper Airway Obstruction
Some Additional References
Here is the review article on which some of the flawed messages of the NEJM piece are based:

* Cricothyrotomy versus Trachetomy: An Otolaryngologist's Perspective. Laryngoscope. 1988 Feb;98(2):131-5.

These two pieces from the ENT and OMFS literature correct these errors:

* Cricothyrotomy: When, Why and Why Not: Am J Otolaryng 2000;21(3):195
* Elective Surgical Cricothyroidotomy in Oral and Maxillofacial Surgery Br J Oral Max Surg 2013;51:779

Now on to the Podcast...
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Scott D. Weingart, MD FCCM clean 21:23
PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad? https://emcrit.org/pulmcrit/esett/ https://emcrit.org/pulmcrit/esett/#comments Sat, 30 Nov 2019 13:20:26 +0000 https://emcrit.org/?p=469282 The management of generalized convulsive status epilepticus remains in perpetual status controversius.  There is consensus that the front-line agent should be a benzodiazepine, but little agreement beyond that.  The much-awaited ESETT trial is a multi-center RCT comparing three anti-epileptic agents for ongoing status epilepticus (levetiracetam, fosphenytoin, and valproate).  This trial will be the highest-quality evidence […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Brain death https://emcrit.org/pulmcrit/brain-death/ https://emcrit.org/pulmcrit/brain-death/#comments Thu, 28 Nov 2019 13:57:37 +0000 https://emcrit.org/?p=469255 Brain death determination and support of a potential organ donor are core topics in critical care.  These topics aren't particularly uplifting or glamorous, so they often are overlooked.  Consultants who don't spend a lot amount of time in the ICU may be uncomfortable with them.  This makes it even more important that we have a […]

EMCrit Project by Josh Farkas.

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PulmCrit- Controlled aquaresis: Management of hypervolemic or euvolemic hyponatremia with oral urea https://emcrit.org/pulmcrit/aquaresis/ https://emcrit.org/pulmcrit/aquaresis/#comments Tue, 26 Nov 2019 13:40:09 +0000 https://emcrit.org/?p=469177 I’ve been yearning to use oral urea for euvolemic hyponatremia for years (e.g. see a post from 2015 here).  Urea has been used in Europe for decades, but until very recently it was unavailable in the United States.  It has numerous advantages compared to the vaptans (which are extremely expensive and potentially dangerous).  Recently, an […]

EMCrit Project by Josh Farkas.

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Tox and Hound – Fellow Friday – Endozepines and Idiopathic Recurrent Stupor https://emcrit.org/toxhound/ff-endozepines/ https://emcrit.org/toxhound/ff-endozepines/#comments Fri, 22 Nov 2019 14:13:35 +0000 https://emcrit.org/?p=468765 Endozepines and Idiopathic Recurrent Stupor From Cholesterol Anesthesia to Anticonvulsant Potatoes and Hepatic Encephalopathy by Steven Curry, M.D.Banner – University Medical Center PhoenixUniversity of Arizona College of Medicine – PhoenixPhoenix, AZ@SteveCurryMD The upcoming traditional Thanksgiving holiday meal along with anticipated postprandial lethargy reminded me of a topic that toxicology fellows should be familiar with and […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast: Hypothermia https://emcrit.org/pulmcrit/hypothermia/ https://emcrit.org/pulmcrit/hypothermia/#comments Thu, 21 Nov 2019 13:41:49 +0000 https://emcrit.org/?p=469105 Hypothermia is a heterogeneous topic.  At one end of the spectrum are previously healthy people who suffer from cold exposure (for whom the rewarming is the primary focus of therapy).  At the other end of the spectrum are patients with mild secondary hypothermia (e.g. due to sepsis), for whom the primary focus is investigation and […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Bupropion intoxication https://emcrit.org/pulmcrit/bupropion/ https://emcrit.org/pulmcrit/bupropion/#comments Thu, 14 Nov 2019 12:20:24 +0000 https://emcrit.org/?p=469006 Most books give bupropion a couple paragraphs, but it arguably deserves its own chapter.  With a decrease in the use of tricyclics and increasing use of bupropion XR for depression, bupropion is becoming the most common cause of life-threatening antidepressant overdose.  Bupropion has a uniquely dangerous property of blocking gap junctions between cardiomyocytes at high […]

EMCrit Project by Josh Farkas.

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EMCrit 259 – Cardiogenic Shock — The Next Level & Mechanical Circulatory Support with Jenelle Badulak https://emcrit.org/emcrit/cardiogenic-shock-2-mcs/ https://emcrit.org/emcrit/cardiogenic-shock-2-mcs/#comments Wed, 13 Nov 2019 13:47:30 +0000 https://emcrit.org/?p=468529 Taking Cardiogenic Shock Management to the next level...

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/cardiogenic-shock-2-mcs/feed/ 4 Taking Cardiogenic Shock Management to the next level...

Back on podcast 10, I discussed the basics of the initial approach to cardiogenic shock. Today, we bring the discussion to the next level...
Our Special Guest
Jenelle Badulak, MD

Acting Assistant Professor of Emergency Medicine, UW Medicine

Dr. Badulak is an emergency physician and intensivist caring for patients in the Cardiothoracic and Medical Intensive Care Units at the University of Washington Medical Center, and in the Trauma Surgical Intensive Care Unit and Emergency Department at Harborview Medical Center.

@JenelleBadulak



How do we know if a patient is in cardiogenic shock and how sick they are?
 

How Should We Start Treatment in the ED
We could center this discussion about the SCAI paper that came out (attached). A nice collaborative expert panel piece outlining a CS pyramid used quickly at the bedside in the ED, ICU, Cath Lab, etc to help us identify these patients and communicate how sick they are to quickly activate escalation of care. It’s gaining traction and it’s way more useful for us in the ED and ICU than INTERMACS.



2) What are the temporary MCS devices out there and when do you decide to use them?:  We could talk through an example algorithm that we use at UW, and many other institutions have developed something similar (attached screen shots from my online textbook corECMO in development).
Characterize the Type and Severity of the Cardiogenic Shock
Evaluate for non-ventricular failure

* Is this a acute valve issue?
* Is this tamponade or another cause of obstructive shock?

Pure Left ventricular vs. Bi-ventricular/RV Failure


Decide on MCS Strategy

Cardiogenic Shock Centers
What is regionalized care for cardiogenic shock?:  This is a super hot topic now, especially with rapidly expanding use of temporary MCS, and needing to rapidly transport patients to centers capable of implanting MCS. Many cities are developing cardiogenic shock hub and spoke models to make it faster and easier to ship these patients to tertiary centers for rescue with temporary MCS and definitive care with comprehensive advanced heart failure therapies.  Often these patients are first recognized to be in bad CS in the ED and if your hospital has nothing but an IABP, I’d argue the best thing to do is ship them instead of admit them.

Additional Resources





* Cardiogenic shock classification Baran 2019
* Cardiogenic shock management statement 2017 AHA
* Cardiogenic Shock Centers Rab JACC 2018

Now on to the Podcast...
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Scott D. Weingart, MD FCCM clean 38:30
Tox and Hound – The Secret Life of Vacor https://emcrit.org/toxhound/vacor/ https://emcrit.org/toxhound/vacor/#comments Tue, 12 Nov 2019 19:05:58 +0000 https://emcrit.org/?p=468906 by Sarah Shafer Vacor was the scourge of rats everywhere in the United States until 1979, when it was removed from the marketplace after we realized that it was not just deadly to rats, but also to humans. It smelled like peanuts, which may have been the reason that it appealed to kids and people […]

EMCrit Project by Tox & Hound.

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EM Nerd-Letter to the Editor, a Response https://emcrit.org/emnerd/em-nerd-letter-to-the-editor-a-response/ https://emcrit.org/emnerd/em-nerd-letter-to-the-editor-a-response/#comments Mon, 11 Nov 2019 21:40:47 +0000 https://emcrit.org/?p=468932 Disclosures: None Recently a letter to the editor was sent to us at the EMCRIT Consortium regarding a recent post I had written about the use of high sensitivity (HS) troponin assays for the work up of ACS in the emergency department. Typically, such remarks are posted in the comments section of the individual blog […]

EMCrit Project by Rory Spiegel.

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Letter to the Editor – High-Sensitivity Troponin is not a Myth, and “Myth-busting” is often another Myth to be Busted https://emcrit.org/emcrit/high-sensitivity-troponin-is-not-a-myth/ https://emcrit.org/emcrit/high-sensitivity-troponin-is-not-a-myth/#comments Sun, 10 Nov 2019 15:34:07 +0000 https://emcrit.org/?p=468693 Shots fired...

EMCrit Project by Scott Weingart.

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PulmCrit Wee – Prophylactic antibiotics after cardiac arrest? https://emcrit.org/pulmcrit/anthartic/ https://emcrit.org/pulmcrit/anthartic/#respond Sat, 09 Nov 2019 10:50:24 +0000 https://emcrit.org/?p=468784 background Pneumonia after cardiac arrest is problematic for several reasons: Many patients aspirate during cardiac arrest. Patients are intubated and mechanically ventilated, usually with poor mental status – conditions which do not promote secretion clearance. Early diagnosis of pneumonia is impossible for many reasons (inability to measure a fever due to therapeutic temperature monitoring, inability […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Acalculous cholecystitis https://emcrit.org/pulmcrit/acalculous-cholecystitis/ https://emcrit.org/pulmcrit/acalculous-cholecystitis/#respond Thu, 07 Nov 2019 12:28:37 +0000 https://emcrit.org/?p=468717 Acalculous cholecystitis is a slippery beast.  It's pretty uncommon, lurking among the myriad of sick ICU patients with moderately abnormal gallbladders.  It is likely both under-diagonsed and over-diagonsed at various times.  Indeed, since surgical cholecystectomy is currently rare, it is frequently unclear whether a patient ever had acalculous cholecystitis!  (For example, if a cholecystostomy drain […]

EMCrit Project by Josh Farkas.

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Tox and Hound – Great! Naloxone worked! Now what? https://emcrit.org/toxhound/naloxone-now-what/ https://emcrit.org/toxhound/naloxone-now-what/#comments Mon, 04 Nov 2019 22:23:00 +0000 https://emcrit.org/?p=468647 by Jon Cole In some ways, you never outgrow your training. Before my medical toxicology fellowship, I completed a residency in emergency medicine. It is my primary specialty and practice, and it’s by far the most common place I encounter most of the patients I see. As opioids have become the primary cause of poisoning […]

EMCrit Project by Tox & Hound.

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PulmCrit – Correlation confounded by timing: One reason we believe bad therapies are awesome https://emcrit.org/pulmcrit/pulmcrit-correlation-confounded-by-timing-why-we-believe-our-therapies-work-when-they-actually-dont/ https://emcrit.org/pulmcrit/pulmcrit-correlation-confounded-by-timing-why-we-believe-our-therapies-work-when-they-actually-dont/#comments Mon, 04 Nov 2019 11:48:28 +0000 https://emcrit.org/?p=468590 example 1: anti-emetics Let’s get started with a RCT comparing droperidol versus ondansetron for the treatment of nausea in the emergency department.  Meek et. al randomized 144 nauseated patients to receive either droperidol or ondansetron.​1​  The rates of symptom improvement were indistinguishable (75% vs 80%).  So, you might conclude that these drugs are equally efficacious. […]

EMCrit Project by Josh Farkas.

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The Dantastic Mr. Tox & Howard – S03E01 – Am vs Have https://emcrit.org/toxhound/s03e01-amvshave/ https://emcrit.org/toxhound/s03e01-amvshave/#respond Fri, 01 Nov 2019 13:54:21 +0000 https://emcrit.org/?p=468212 Compassionate care and why words matter with Bill Kinkle Join Dan (@drusyniak) &Howard (@heshiegreshie) as they set out to change the conversation about substance use with Bill Kinkle (@billkinkle). This one comes with a warning. We will discuss graphic descriptions of drug use, addiction behaviors and stigmatizing language. Help us to end the stigma associated […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast – Carbon monoxide poisoning https://emcrit.org/pulmcrit/co/ https://emcrit.org/pulmcrit/co/#comments Thu, 31 Oct 2019 13:31:42 +0000 https://emcrit.org/?p=468509 In the northern hemisphere, Winter is Coming.  Folks are firing up their furnaces – some of which may have an inadequate oxygen supply, thereby generating carbon monoxide.  Unfortunately, the diagnosis of carbon monoxide poisoning is extremely hard to make, mimicking many different conditions.  In particular, carbon monoxide poisoning can mimimic influenza – which is also […]

EMCrit Project by Josh Farkas.

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EMCrit 258 – Should Andexxa be added to a Hospital’s Formulary? https://emcrit.org/emcrit/andexxa-formulary/ https://emcrit.org/emcrit/andexxa-formulary/#respond Sat, 26 Oct 2019 19:28:35 +0000 https://emcrit.org/?p=468245 Should hospitals stock Andexxa?

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/andexxa-formulary/feed/ 0 Should hospitals stock Andexxa?
* Peled et al. Key Points to Consider When Evaluating Andexxa for Formulary Addition. Neurocrit Care 10.1007/s12028-019-00866-6

Dr. Harry Peled is the medical director of Cardiology and Critical Care at St Jude Medical Center in California. Relevantly, he is also chair of the Pharmacy an Therapeutics Committee.

I would love to hear your thoughts on this issue--place them in the comments below.
See Also

* I Have Issues with Andexanet by K. Kipp, PharmD

Now on to the Podcast...]]>
Scott D. Weingart, MD FCCM clean 19:00
IBCC chapter & cast: Post-MI complications https://emcrit.org/pulmcrit/post-mi-complications/ https://emcrit.org/pulmcrit/post-mi-complications/#comments Thu, 24 Oct 2019 12:29:21 +0000 https://emcrit.org/?p=468159 Myocardial infarction patients are complex.  Unfortunately, this complexity can grow over time.  Delayed deterioration in the patient recovering from MI may result from a host of different problems (e.g. medication effect, procedural complications, or merely the natural history of the disease).  This chapter explores some problems that we should be on the lookout for in […]

EMCrit Project by Josh Farkas.

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Guest Post – The 3D Printed Endobronchial Trainer by Matt Mac Partlin https://emcrit.org/emcrit/endobronchial-trainer/ https://emcrit.org/emcrit/endobronchial-trainer/#comments Wed, 23 Oct 2019 15:31:55 +0000 https://emcrit.org/?p=467725 Train on massive hemoptysis

EMCrit Project by Guest Author.

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PulmCrit- Metoprolol causes harm in COPD?? Déjà vu all over again https://emcrit.org/pulmcrit/metoprolol-copd/ https://emcrit.org/pulmcrit/metoprolol-copd/#comments Wed, 23 Oct 2019 12:07:20 +0000 https://emcrit.org/?p=468111 We’ve been all over the road with beta-blockers and COPD.  For a long time, there was a belief that beta-blockers were contraindicated in COPD.  Eventually that concept fell out of favor.  Subsequently, some correlative data suggested that beta-blockers might be beneficial in COPD.  This led to the current BLOCK-COPD trial which (spoiler alert) shows that […]

EMCrit Project by Josh Farkas.

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Tox and Hound – Color Me Blue https://emcrit.org/toxhound/colormeblue/ https://emcrit.org/toxhound/colormeblue/#comments Mon, 21 Oct 2019 14:06:08 +0000 https://emcrit.org/?p=468049 by Christine Murphy Alternative Uses for Methylene Blue I like finding alternative uses for existing antidotes. Antidote research is very limited – let's be honest, there isn't a huge market out there for most antidotes. So, anytime an existing antidote's use can be expanded to other indications, I think that is a win. Methylene blue […]

EMCrit Project by Tox & Hound.

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PulmCrit Wee: Do fluid boluses before intubation help? (PREPARE trial) https://emcrit.org/pulmcrit/prepare/ https://emcrit.org/pulmcrit/prepare/#comments Mon, 21 Oct 2019 12:31:59 +0000 https://emcrit.org/?p=467955 I’m afraid she will tank after intubation, could you start some fluid? I brought a liter of fluid, just in case the blood pressure falls after intubation.  He is decompensating!  Run the fluid wide open! We’ve all probably heard and spoken those phrases.  Crystalloid is a traditional therapy in efforts to either prevent or mitigate […]

EMCrit Project by Josh Farkas.

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PulmCrit- Commentary on the new pneumonia guidelines using GIFs & some mini-rants https://emcrit.org/pulmcrit/idsa-cap-guidelines/ https://emcrit.org/pulmcrit/idsa-cap-guidelines/#comments Sat, 19 Oct 2019 09:54:32 +0000 https://emcrit.org/?p=467729 So, the new IDSA guidelines for community acquired pneumonia (CAP) are here.  This post will walk us through the guidelines, focusing primarily on issues that relate to critically ill patients.  Guidelines can get dull, I've added in GIFs to illustrate my feelings about each recommendation & kept things pretty informal.  Come for the GIFs, stay […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Methemoglobinemia https://emcrit.org/pulmcrit/methemoglobinemia/ https://emcrit.org/pulmcrit/methemoglobinemia/#comments Thu, 17 Oct 2019 11:22:53 +0000 https://emcrit.org/?p=467948 Methemoglobinemia is one of my favorite toxicology diagnoses.  The diagnosis can often be made at the bedside based on history and physical examination, which is a satisfying bit of detective work.  Once the diagnosis is made, patients generally respond promptly to a specific antidote (methylene blue).  And this isn't just a parlor trick – diagnosis […]

EMCrit Project by Josh Farkas.

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PulmCrit- Tranexamic acid for traumatic brain injury (CRASH3) https://emcrit.org/pulmcrit/crash3/ https://emcrit.org/pulmcrit/crash3/#comments Mon, 14 Oct 2019 22:01:44 +0000 https://emcrit.org/?p=467810 preamble CRASH-3 is the latest massive, pragmatic multi-center RCT brought to us by the London School of Hygiene and Tropical Medicine Trials Unit.  These investigators have created an extensive network of hospitals throughout the world with the capability of performing truly impressive trials.  Especially in the critical care arena, these trials have uniquely high power […]

EMCrit Project by Josh Farkas.

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EM Nerd-The Case of the Indecisive Antidote https://emcrit.org/emnerd/em-nerd-the-case-of-the-indecisive-antidote/ https://emcrit.org/emnerd/em-nerd-the-case-of-the-indecisive-antidote/#comments Mon, 14 Oct 2019 22:00:16 +0000 https://emcrit.org/?p=467864 Studies examining the use of tranexamic acid (TXA) inescapably seem to pit our methodological rigorous demons against our practical clinical angels.  The CRASH-2 trial published in the Lancet in 2010 by Shakur et al, randomized 20,211 adult trauma patients presenting to 274 hospitals in 40 different countries to receive 1g of TXA over 10 min […]

EMCrit Project by Rory Spiegel.

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Tox and Hound – Up in Smoke https://emcrit.org/toxhound/upinsmoke/ https://emcrit.org/toxhound/upinsmoke/#comments Mon, 14 Oct 2019 16:33:14 +0000 https://emcrit.org/?p=467824 by Trevonne Thompson The Outbreak of Electronic Cigarette Use and Pulmonary Injury There is currently an outbreak of pulmonary injury associated with electronic cigarette use. As of October 8, 2019, the Centers for Disease Control and Prevention (CDC) reports 1,299 cases of lung injury associated with electronic cigarette use from 49 states and 1 U.S. […]

EMCrit Project by Tox & Hound.

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IBCC asthma chapter post-publication peer review by Weingart https://emcrit.org/pulmcrit/asthma-peer-review/ https://emcrit.org/pulmcrit/asthma-peer-review/#comments Fri, 11 Oct 2019 13:49:00 +0000 https://emcrit.org/?p=467782 Sometimes muggles criticize FOAM as lacking peer review, but that simply reflects a misunderstanding of the way peer review works here.  FOAMed operates off a post-publication peer review system.  This typically occurs mostly in the comments section of each blog or chapter (with some on twitter as well).  Unlike journals, anyone is free to leave […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Diffuse alveolar hemorrhage & ANCA vasculitis https://emcrit.org/pulmcrit/dah/ https://emcrit.org/pulmcrit/dah/#respond Thu, 10 Oct 2019 12:08:06 +0000 https://emcrit.org/?p=467751 Diffuse alveolar hemorrhage is encountered uncommonly, but it is useful to have a general understanding of this.  Many etiologies can cause diffuse alveolar hemorrhage, with pulmonary vasculitis being perhaps the most widely feared.  This chapter explores how to sift through the differential diagnosis of diffuse alveolar hemorrhage and, if vasculitis is suspected, how to initiate […]

EMCrit Project by Josh Farkas.

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EMCrit 257 – Pulseless Electrical Activity (PEA) is Stupid https://emcrit.org/emcrit/pea-is-stupid/ https://emcrit.org/emcrit/pea-is-stupid/#comments Wed, 09 Oct 2019 14:21:06 +0000 https://emcrit.org/?p=467317 Pulseless Electrical Activity ( PEA ) is confusing! The diagnosis and treatment of PEA is bogged down by terminology and misunderstandings. Spurred by a recent interview I did with Anton Helman of EM Cases, I lay down some of my thoughts on PEA here. The last time I discussed these issues was 5 years ago […]

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/pea-is-stupid/feed/ 18 Pulseless Electrical Activity ( PEA ) is confusing! The diagnosis and treatment of PEA is bogged down by terminology and misunderstandings. Spurred by a recent interview I did with Anton Helman of EM Cases, I lay down some of my thoughts on PEA here. Pulseless Electrical Activity ( PEA ) is confusing! The diagnosis and treatment of PEA is bogged down by terminology and misunderstandings. Spurred by a recent interview I did with Anton Helman of EM Cases, I lay down some of my thoughts on PEA here.



The last time I discussed these issues was 5 years ago with Zack and Joe on EDECMO 13.



PEA Progression to ROSC







POCUS Pulse



* Carotid POCUS Pulse* Badra et al. on POCUS Pulse







Narrow / Wide doesn't Work



Rory breaks it down on the CCnerd in a post about QRS size in PEA.



What to Do if You Have Compressions/POCUS Pulse but No BP



Prosen on Vasopressin for PEA



Critical Care and Neurocritical Care Boards Review Book







Mayo Clinic Board Review



Just fantastic! (Note: i received a reviewers' copy of this book)



Updates



More on PEA on the EM Cases Blog - I speak with Anton Helman on the topic



The Right Heart being Big doesn't mean PE during Arrest (from Ultrasound Podcast)



Now on to the Podcast...




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Scott D. Weingart, MD FCCM clean 31:38
EM Nerd-The Case of the Hurried Objective https://emcrit.org/emnerd/em-nerd-the-case-of-the-hurried-objective/ https://emcrit.org/emnerd/em-nerd-the-case-of-the-hurried-objective/#comments Tue, 08 Oct 2019 20:57:14 +0000 https://emcrit.org/?p=467644 In 2015, Centers for Medicare & Medicaid (CMS) published their sepsis core measure (SEP-1). This represented a nationally mandated sepsis management strategy presented in the form of a 3 and 6-hour bundle. Since its publication, the Surviving Sepsis Campaign (SSC) released their own 1-hour bundle (1), adding even more urgency to an already frenetic effort […]

EMCrit Project by Rory Spiegel.

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IBCC chapter & cast – Asthma https://emcrit.org/pulmcrit/asthma/ https://emcrit.org/pulmcrit/asthma/#comments Tue, 08 Oct 2019 13:56:10 +0000 https://emcrit.org/?p=467631 Severe asthma is a challenging topic, because this spans a lot of different patient phenotypes with varying severity and physiology.  This chapter attempts to outline some general principles to guide management, but ultimately clinical judgement and serial evaluation at the bedside will trump all of this.  The rarity, acuity, and heterogeneity of severe asthma make […]

EMCrit Project by Josh Farkas.

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Tox and Hound – Don’t Wernicke’s, B(1) Happy https://emcrit.org/toxhound/wernickes/ https://emcrit.org/toxhound/wernickes/#comments Mon, 07 Oct 2019 13:49:00 +0000 https://emcrit.org/?p=467575 by Meghan Spyres You take the perilous sign out of a 55-year-old patient with alcohol use disorder (AUD) who came to the ED intoxicated. “He’s just metabolizing” your colleague tells you. A few hours go by and he is now awake and asking to leave. The nurse road tests him and he can walk, but […]

EMCrit Project by Tox & Hound.

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