EMCrit Project https://emcrit.org Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Fri, 22 Feb 2019 15:48:08 +0000 en-US hourly 1 https://wordpress.org/?v=5.0.3 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 Podcast 241 – Sepsis Update 2019 https://emcrit.org/emcrit/emcrit-podcast-241-sepsis-update-2019/ https://emcrit.org/emcrit/emcrit-podcast-241-sepsis-update-2019/#respond Thu, 21 Feb 2019 16:39:43 +0000 http://emcrit.org/?p=459740 New stuff on sepsis resuscitation for 2019

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/emcrit-podcast-241-sepsis-update-2019/feed/ 0 New stuff on sepsis resuscitation for 2019
A bunch of fun new ideas re: sepsis for 2019
Fluids
30 ml/kg may be based on IBW if you write in the chart that that was what you were using
Andromeda-Shock Trial
A fascinating study by Hernandez et al.1



See Rory's take on it
Censer Trial
Early fixed-dose norepi use was examined in this trial.2

https://www.thebottomline.org.uk/summaries/icm/censer/
Procalcitonin
HiTemp Study3

Procalcitonin was poor for differentiating bacterial infections and other causes of fever in the ED.
Now on to the Podcast...





1.
Hernández G, Ospina-Tascón G, Damiani L, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019;321(7):654-664. [PubMed]




2.
Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER) : A Randomized Trial. Am J Respir Crit Care Med. February 2019. [PubMed]




3.
van der, Limper M, Jie K, et al. Procalcitonin-guided antibiotic therapy in patients with fever in a general emergency department population: a multicentre non-inferiority randomized clinical trial (HiTEMP study). Clin Microbiol Infect. 2018;24(12):1282-1289. [PubMed]



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Scott D. Weingart, MD FCCM clean 19:44
IBCC chapter & cast: Hypernatremia https://emcrit.org/pulmcrit/hypernatremia-2/ https://emcrit.org/pulmcrit/hypernatremia-2/#comments Thu, 21 Feb 2019 12:26:27 +0000 https://emcrit.org/?p=460019 Treating hypernatremia in the ICU isn't exciting or particularly difficult.  However, it's enormously important to provide patients with comfort.  We talk a lot on treating pain, but usually forget about the discomfort caused by thirst.  Remember:  when you intubate a patient and take control of their airway, you're also taking responsibility to provide them with water.

EMCrit Project by Josh Farkas.

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EM Nerd-The Case of the Deceitful Lantern https://emcrit.org/emnerd/em-nerd-the-case-of-the-deceitful-lantern/ https://emcrit.org/emnerd/em-nerd-the-case-of-the-deceitful-lantern/#comments Tue, 19 Feb 2019 14:12:12 +0000 https://emcrit.org/?p=459923 Since the publication of the sepsis trilogy, PROMISE, ARISE, and PROCESS 1,2,3, abruptly displaced early goal directed therapy (EGDT) as the cornerstone of sepsis management, we have been searching to fill the therapeutic vacuum its sudden departure left behind. The Center for Medicare and Medicaid Services (CMS) and the Surviving Sepsis Campaign (SSC) have both rushed […]

EMCrit Project by Rory Spiegel.

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PulmCrit: Is pure RSI a failed paradigm in critical illness? The primacy of pressure https://emcrit.org/pulmcrit/pressure-rsi/ https://emcrit.org/pulmcrit/pressure-rsi/#comments Tue, 19 Feb 2019 13:12:16 +0000 https://emcrit.org/?p=459880 Why do some patients' saturation crash during laryngoscopy, whereas other patients are fine?  What can we do to prevent this?

EMCrit Project by Josh Farkas.

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Tox and Hound – Talking Back to a Talking Antidote https://emcrit.org/toxhound/talkingantidote/ https://emcrit.org/toxhound/talkingantidote/#respond Mon, 18 Feb 2019 19:29:40 +0000 https://emcrit.org/?p=459857 By Andrew Stolbach Author’s note: I sat down to discuss the role of the out-of-hospital naloxone administration with Evzio® (Kaleo Pharmaceuticals), the world’s only talking naloxone auto-injector. Our interview is presented below in its entirety. AS: Thanks for coming today. Evzio®: To Inject. Place black end against outer thigh. Then press firmly. 5, 4, 3, […]

EMCrit Project by Tox & Hound.

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IBCC chapter: Salicylate intoxication https://emcrit.org/pulmcrit/salicylates/ https://emcrit.org/pulmcrit/salicylates/#respond Thu, 14 Feb 2019 11:45:37 +0000 http://emcrit.org/?p=459801 Of all intoxications, salicylates is one of the most important to understand.  These cases can unravel rapidly, with fatal outcome.  However, with prompt management most patients will do fine.  Treatment depends on a solid grasp of the underlying chemistry and renal physiology.

EMCrit Project by Josh Farkas.

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Point of Care Ultrasound Handbook – RUSH Chapter https://emcrit.org/emcrit/point-of-care-ultrasound-rush/ https://emcrit.org/emcrit/point-of-care-ultrasound-rush/#comments Wed, 13 Feb 2019 01:27:52 +0000 http://emcrit.org/?p=449170 A free chapter from a POC ultrasound book

EMCrit Project by Guest Author.

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PulmCrit: The surviving sepsis campaign 1-hour bundle is… back? https://emcrit.org/pulmcrit/ssc-1-hour/ https://emcrit.org/pulmcrit/ssc-1-hour/#comments Tue, 12 Feb 2019 11:47:21 +0000 http://emcrit.org/?p=459475 The surviving sepsis campaign (SSC) has had substantial problems dating back to its inception.  The original backbone of the guidelines was a single-center trial by Rivers, which has largely been debunked.1–4  Initially the SSC was slow to let go of invasive early goal-directed therapy.  The SSC has finally started eliminating older dogma (e.g., superior vena cava […]

EMCrit Project by Josh Farkas.

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The Case of the Scientific Ruse https://emcrit.org/emnerd/the-case-of-the-scientific-ruse/ https://emcrit.org/emnerd/the-case-of-the-scientific-ruse/#comments Mon, 11 Feb 2019 21:22:32 +0000 http://emcrit.org/?p=459723 February 7th 2019 marked a auspicious day in the history of the NEJM and its relationship with the pharmaceutical industry. In 2015, the NEJM shifted their significant weight in support of a strong union between industry and medicine1,2,3. With the simultaneous publication of four pharmaceutical sponsored trials, each brimming with its own unique form of […]

EMCrit Project by Rory Spiegel.

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Tox and Hound – No GABA GABA! https://emcrit.org/toxhound/no-gaba-gaba/ https://emcrit.org/toxhound/no-gaba-gaba/#respond Mon, 11 Feb 2019 16:57:57 +0000 https://emcrit.org/?p=459649 by Howard Greller We rarely stop and appreciate the beauty that is reflected in our physiology. It’s not until something goes wrong that we recognize how well things were working. For example, our brains . . . An analogy I like is that our brains are like a car (I definitely need to upgrade to […]

EMCrit Project by Tox & Hound.

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IBCC chapter: Buprenorphine & opioid use disorder https://emcrit.org/pulmcrit/buprenorphine/ https://emcrit.org/pulmcrit/buprenorphine/#respond Mon, 11 Feb 2019 11:45:50 +0000 http://emcrit.org/?p=459692 In critical care, we’ve been treating patients with opioid use disorder for a long time.  If they’re intubated for intoxication, we extubate them and send them home.  If they’re septic with endocarditis, we treat their sepsis.  Unfortunately, this isn’t enough.  We’re treating the complications of opioid use disorder, without addressing the underlying problem. Recently, medication-assisted […]

EMCrit Project by Josh Farkas.

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EMCrit Podcast 240 – Renal Compartment Syndrome & It’s all about the Venous Side and We’ve Been Fracking it up for Years https://emcrit.org/emcrit/renal-compartment-syndrome-chf/ https://emcrit.org/emcrit/renal-compartment-syndrome-chf/#comments Sun, 10 Feb 2019 14:38:23 +0000 http://emcrit.org/?p=459590 Renal Compartment Syndrome, Venous Congestion, CHF, and POCUS.

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/renal-compartment-syndrome-chf/feed/ 7 Renal Compartment Syndrome, Venous Congestion, CHF, and POCUS. Newest Member of the EMCrit Team: Phillippe Rola
ThinkingCC

Internist-Intensivist in Montreal, Canada, Mad Sonographer, Proud Daddy and Husband, and sometimes jiujitero.

Editor-in-Chief of ThinkingCriticalCare.com
POCUS Portal Vein from the Case

More on the Discussion in the Podcast on Thinking Critical Care

* Physiological Resuscitation
POCUS, Mythology and Hemodynamic Awesomeness

H&R 2019 Conference

* All info
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Scott D. Weingart, MD FCCM clean 21:26
IBCC chapter: Thyroid storm https://emcrit.org/pulmcrit/thyroid-storm-2/ https://emcrit.org/pulmcrit/thyroid-storm-2/#comments Thu, 07 Feb 2019 12:33:37 +0000 http://emcrit.org/?p=459525 Thyroid storm is a bit of a zebra.  It can mimic a variety of common conditions (e.g. sepsis, delirium, heart failure).  Unfortunately, if you're not looking for it, you probably won't find it.   Once identified, an organized multimodal treatment regimen will generally get the job done.  But be careful - these patients may have varying physiology, so blindly following the same rubric for every single patient isn't the answer.

EMCrit Project by Josh Farkas.

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Tox and Hound – Not For Human Consumption https://emcrit.org/toxhound/not-for-human-consumption/ https://emcrit.org/toxhound/not-for-human-consumption/#comments Mon, 04 Feb 2019 17:20:11 +0000 https://emcrit.org/?p=459459 by Dan Rusyniak At my poison center we have seen an increasing number of a calls related to a drug I had never heard of – Tianeptine. Tianewhat? Yes, I thought the same. Although I had not heard of it, this is a drug that has been around since the 1970’s. Synthesized in the 60’s […]

EMCrit Project by Tox & Hound.

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The Case of the Incidental Bystander Continues https://emcrit.org/emnerd/the-case-of-the-incidental-bystander-continues/ https://emcrit.org/emnerd/the-case-of-the-incidental-bystander-continues/#comments Fri, 01 Feb 2019 13:48:29 +0000 http://emcrit.org/?p=459437 In October 2016 the Emergency Medicine community was faced with the publication of the now infamous PESIT trial, and the symbolic wrench its authors carelessly tossed into the already indecisive diagnostic work up of patients presenting to the Emergency Department following a syncopal event1. Published in the NEJM, Prandoni et al enrolled patients who were admitted […]

EMCrit Project by Rory Spiegel.

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IBCC chapter & cast: thrombocytopenia & HITT https://emcrit.org/pulmcrit/thrombocytopenia/ https://emcrit.org/pulmcrit/thrombocytopenia/#comments Thu, 31 Jan 2019 11:11:45 +0000 http://emcrit.org/?p=459418 Thrombocytopenia is extremely common in critical illness.  It's generally a consequence rather than a cause of illness, predicting increased mortality.  However, we must remain alert for cases where serious hematologic disease is afoot.  The major concern here is the ever-looming possibility of heparin-induced thrombocytopenia and thrombosis (HITT).  This chapter explores thrombocytopenia and provides an evidence-based […]

EMCrit Project by Josh Farkas.

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The Case of the False Dichotomy https://emcrit.org/emnerd/the-case-of-the-false-dichotomy/ https://emcrit.org/emnerd/the-case-of-the-false-dichotomy/#comments Wed, 30 Jan 2019 00:47:35 +0000 http://emcrit.org/?p=459390 Often in the interpretation of medical literature we are forced into false dichotomies. Compelled to choose between two hypotheses, neither of which are representative of the data presented. Such is the case with a recent trial published in Intensive Care Medicine in which Guitton et al1 examine the efficacy of apneic oxygenation during RSI in critically […]

EMCrit Project by Rory Spiegel.

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The Dantastic Mr. Tox & Howard – S02E07 – Release the Kratom https://emcrit.org/toxhound/s02e07-release-the-kratom-2/ https://emcrit.org/toxhound/s02e07-release-the-kratom-2/#respond Tue, 29 Jan 2019 06:40:37 +0000 https://emcrit.org/?p=459377 Alternative treatments for opioid use disorder and music with Dr. Ed Boyer Join Dan (@drusyniak) &Howard (@heshiegreshie) as they speak with Dr. Ed Boyer about therapies for opioid use disorder, including kratom, ibogaine, and loperamide. Great stuff, deep science and a dispelling of some myths while recognizing some less than savvy science out there. . […]

EMCrit Project by Tox & Hound.

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PulmCrit- Inhaled NO for submassive PE: iNOPE or iYEP? https://emcrit.org/pulmcrit/inope/ https://emcrit.org/pulmcrit/inope/#comments Mon, 28 Jan 2019 11:47:08 +0000 http://emcrit.org/?p=459337 The use of an inhaled pulmonary vasodilator is a logical strategy for stabilization of PE patients (especially nitric oxide, which may be depleted in this situation). Previously inhaled nitric oxide has only been supported by case series.

EMCrit Project by Josh Farkas.

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EMCrit 239 – Vent Alarms = Code Blue https://emcrit.org/emcrit/vent-alarms/ https://emcrit.org/emcrit/vent-alarms/#comments Sat, 26 Jan 2019 22:00:59 +0000 http://emcrit.org/?p=459293 All things Vent Alarms

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/vent-alarms/feed/ 5 All things Vent Alarms Vent Alarms should be Regarded as Code Blue
If you cannot instill this into your culture, patients will die

If they are crashing, do DOPES
ETCO2 on any Vented Pt
This is what the real alarm should be
High (Peak) Pressure

Dyssynchrony
Peak Only

* Check the circuit

* fluid pooling in circuit
* fluid pooling in filter
* kinking of circuit


* Tube too small or biofilmed
* Bronchospasm
* Biting on ETT
*

Peak & Plat High

* Tube in Mainstem
* Pneumothorax
* Bad Lungs >> Turn down the Vt
* Abd Compartment

Low Peak Pressure

* Disconnect
* ETT Cuff Deflated
* Pt effort

Low Ve/Vt

* Cuff Issues (See EMCrit Wee )
* Bronchopleural Fistula

Low O2 Alarm

* Not hooked Up
* Gases Messed Up
* Sensor Messed up

What to Do with Continued Alarms Despite Sedation, Equipment Check, Suctioning

* Consider Bronchoscopic Assessment
* If Patient begins to crash, consider tube exchange if bronch not available

Breakdown on Alarm Types
Article on Vent Alarm Stats 1


See More
High-Peek on ALIEM




1.
Cvach M, Stokes J, Manzoor S, et al. Ventilator Alarms in Intensive Care Units: Frequency, Duration, Priority, and Relationship to Ventilator Parameters. Anesth Analg. September 2018. [PubMed]



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Scott D. Weingart, MD FCCM clean 21:27
IBCC chapter: Antibiotics for the critically ill patient https://emcrit.org/pulmcrit/antibiotics/ https://emcrit.org/pulmcrit/antibiotics/#comments Thu, 24 Jan 2019 14:25:34 +0000 http://emcrit.org/?p=459313 We spend a lot of time obsessing over the finer details of critical care:  which fluid is best?  which vasopressor is best?  will another liter of fluid help?  These details are important, but for a septic patient something more important than any of these details is choosing the right antibiotic(s).  In septic shock, source control and […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Undifferentiated shock https://emcrit.org/pulmcrit/shock/ https://emcrit.org/pulmcrit/shock/#comments Thu, 17 Jan 2019 15:06:03 +0000 http://emcrit.org/?p=458596 Shock is the next-door neighbor of death.  Shock can present in a myriad of different forms, making early recognition challenging.  However, early diagnosis is essential.  Shock can be caused by a broad differential of serious illnesses.  Unlike most differential diagnosis lists, every item on this differential is life-threatening.  Fortunately, many causes of shock are reversible […]

EMCrit Project by Josh Farkas.

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EMCrit Wee – Getting Things Done 2019 Update https://emcrit.org/emcrit/gtd2019/ https://emcrit.org/emcrit/gtd2019/#comments Wed, 16 Jan 2019 22:50:06 +0000 http://emcrit.org/?p=456498 GTD Update for 2019

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/gtd2019/feed/ 4 GTD Update for 2019 Original GTD (Gettin' Sh*t Done) Posts

* EMCrit Podcast 136 - Getting Shit Done
* EMCrit Podcast 209 - GTD Redux - Opportunities, Time, & Future Selves

Switched to Todoist

* Todoist Summary
* Integration with Gcal
* IFTTT and Zapier

Massive Action Planning by Tony Robbins


* Write down the results you want to achieve. (be specific, quantitate if possible)
* Write down your purpose (compelling reasons why you want to accomplish this goal--use trigger words, emotion)
* Develop a sequence of priority actions.

or as Carl Pullein discusses, OPA:

Outcome, Purpose, Actions


Inboxes are Deadly
Prune, prune, prune

Use email inbox for everything (shortcut/workflow on ios & boomerang on firefox)
Inbox Zero
Boomerang
Subconscious Cognitive Bandwidth
It is not the time, it is the weight

Checklists
If anything you do is:

1. Fiddly &

2. Infrequent

Make a checklist
Directly Responsible Person (DRI)
Who is the the DRI directly responsible individual from Jobs/Apple

Problem for Future Homer
Why we don't care about our future selves


Now on to the Wee...]]>
Scott D. Weingart, MD FCCM clean 23:57
PulmCrit- Vancomycin pharmacokinetics: Make vanco great again https://emcrit.org/pulmcrit/vanco/ https://emcrit.org/pulmcrit/vanco/#comments Wed, 16 Jan 2019 14:36:22 +0000 http://emcrit.org/?p=457864 Traditionally, vancomycin doses have been adjusted to target a specific trough level.  However, it is increasingly clear that the trough level is an inadequate measurement of vancomycin exposure.  Furthermore, the practice of waiting until the fourth dose to measure the trough level may expose the patient to days of suboptimal therapy.

EMCrit Project by Josh Farkas.

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Tox and Hound – Some Like It Hot https://emcrit.org/toxhound/likeithot/ https://emcrit.org/toxhound/likeithot/#respond Mon, 14 Jan 2019 18:26:14 +0000 https://emcrit.org/?p=457509 by Meghan Spyres The holidays are over and it’s time for that long stretch of thankless winter before spring is here again. Sounds like the perfect time to plan a trip somewhere tropical! Which also makes it the perfect time to review one of my favorite topics: marine envenomations. Although we typically think of the […]

EMCrit Project by Tox & Hound.

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PulmCrit- Acute infection & myocardial infarction: How afraid should we be? https://emcrit.org/pulmcrit/infection-mi/ https://emcrit.org/pulmcrit/infection-mi/#comments Mon, 14 Jan 2019 13:19:48 +0000 http://emcrit.org/?p=457465 Occasionally, the NEJM publishes a scary article that gets a lot of press, but doesn’t pan out to be valid.  The recent example is the PESIT study, which seemed to imply that everyone admitted with syncope had PE (don’t worry- they don’t). It looks like NEJM might be at it again, with this week’s review article on the relationship between acute infection and MI.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Severe influenza https://emcrit.org/pulmcrit/influenza/ https://emcrit.org/pulmcrit/influenza/#comments Thu, 10 Jan 2019 14:24:29 +0000 http://emcrit.org/?p=456787 Initially I wasn't planning to write a chapter on influenza, because there is precious little evidence regarding ICU management.  However, even in the absence of solid evidence, we will be called upon to treat these patients.  Currently flu season is afoot, and it looks like it might be a bad one (with a predominance of […]

EMCrit Project by Josh Farkas.

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COMM CHECK: On Checklists https://emcrit.org/emcrit/comm-check-on-checklists/ https://emcrit.org/emcrit/comm-check-on-checklists/#comments Thu, 03 Jan 2019 16:01:49 +0000 http://emcrit.org/?p=455321 The Checklist that Saved an Aircraft On October 30, 1935 Boeing engineers stood proudly by as their newest technological wonder, the Model 299 was about to demonstrate its capabilities to members of the  top brass of the Army Air Corps.  At the controls of the aircraft was the Army’s chief test pilot, Major Ployer P. […]

EMCrit Project by Mike Lauria.

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IBCC chapter & cast: Acute Kidney Injury https://emcrit.org/pulmcrit/acute-kidney-injury/ https://emcrit.org/pulmcrit/acute-kidney-injury/#comments Wed, 02 Jan 2019 20:51:07 +0000 http://emcrit.org/?p=456607 The importance of avoiding and treating renal failure cannot be overstated.  The kidneys are delicate organs, often the first to be injured by systemic hypoperfusion or other insults.  Severe renal dysfunction leads to a cascade of badness, promoting the failure of other organs and eventual spiraling into multi-organ failure.1  Alternatively, if we are can defend […]

EMCrit Project by Josh Farkas.

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Tox and Hound – A Happy New Year To All! https://emcrit.org/toxhound/happynewyear/ https://emcrit.org/toxhound/happynewyear/#comments Mon, 31 Dec 2018 23:13:33 +0000 https://emcrit.org/?p=456551 7 Cyanide Wishes and Thallium Dreams! Howard – The story of the year? The Tox and The Hound! Toxicology’s foray into the world of FOAM has had an auspicious start. I am obviously biased, but I think that we have a phenomenal team and have put forth some outstanding content. From toxicology·fundamentals, to the classics (including […]

EMCrit Project by Tox & Hound.

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PulmCrit- Antibiotics for abscesses, white walkers, and the inherent myopia of science https://emcrit.org/pulmcrit/antibiotics-abscess/ https://emcrit.org/pulmcrit/antibiotics-abscess/#comments Mon, 31 Dec 2018 11:00:04 +0000 http://emcrit.org/?p=456500 There are a number of reasons that an idea may be impossible to test scientifically.  Perhaps the disease state that the idea applies to is extremely rare.  Perhaps it is logistically impossible to test the idea, due to issues with blinding or time constraints.  This post will focus on an insidious reason that ideas are thrown beyond the wall:  the timeframe and study size required to test them are unachievable.

EMCrit Project by Josh Farkas.

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CC Nerd-The Case of the Unknown Quantity https://emcrit.org/emnerd/cc-nerd-the-case-of-the-unknown-quantity/ https://emcrit.org/emnerd/cc-nerd-the-case-of-the-unknown-quantity/#comments Sat, 29 Dec 2018 20:01:11 +0000 http://emcrit.org/?p=456479 Lung-protective ventilation is often considered a simple truth when managing critical care patients on mechanical ventilation. Despite this sense of certainty, the knowledge of exactly how and when to perform such ventilatory strategies is incomplete. The recently published PReVENT adds yet more uncertainty to the true efficacy of low tidal volume ventilation in patients without […]

EMCrit Project by Rory Spiegel.

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Tox and Hound – Fellow Friday – Drug and Toxin-Induced Hepatic Microvesicular Steatosis https://emcrit.org/toxhound/ff-microvesicular-steatosis/ https://emcrit.org/toxhound/ff-microvesicular-steatosis/#comments Fri, 28 Dec 2018 17:58:00 +0000 https://emcrit.org/?p=456420 Drug and Toxin-Induced Hepatic Microvesicular Steatosis From Captain Bligh to Bacillus cereus by Steven Curry, M.D. Department of Medical Toxicology Banner – University Medical Center Phoenix @SteveCurryMD Drug and toxin-induced liver diseases comprise various histologic patterns. A few examples a toxicologist may encounter include perisinusoidal fibrosis with hypervitaminosis A, peliosis hepatis from sex steroids, veno-occlusive […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast: Community-acquired urosepsis https://emcrit.org/pulmcrit/urosepsis/ https://emcrit.org/pulmcrit/urosepsis/#comments Wed, 26 Dec 2018 18:21:34 +0000 http://emcrit.org/?p=456381 Urosepsis is one of my favorite ICU diagnoses.  In almost all cases, patients will improve dramatically within 12-24 hours and leave the ICU with minimal sequelae.  But that shouldn't lull us into a false sense of security:  careful antibiotic selection, aggressive resuscitation, and (in some cases) emergent drainage may be required for a good outcome.  

EMCrit Project by Josh Farkas.

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The Dantastic Mr. Tox & Howard – S02E06 – The Ergogenic Academic https://emcrit.org/toxhound/s02e06-ergogenic-academic/ https://emcrit.org/toxhound/s02e06-ergogenic-academic/#respond Tue, 25 Dec 2018 13:57:50 +0000 https://emcrit.org/?p=456351 Dantastic Live at NACCT 2018 . . . &Howard That’s not a lump of coal in your stocking . . . Join Dan (@drusyniak) &Howard (@heshiegreshie) as they speak with Dr. Dan Rusyniak (@drusyniak) live on stage at the 2018 North American Congress of Clinical Toxicology Pre-Meeting Symposium. Dan cleverly tricked Howard into being the foil […]

EMCrit Project by Tox & Hound.

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Tox and Hound – Reefer Madness https://emcrit.org/toxhound/reefer-madness/ https://emcrit.org/toxhound/reefer-madness/#comments Thu, 20 Dec 2018 22:18:25 +0000 https://emcrit.org/?p=456231 by Diane Calello The decision to move from a system in which cannabis is completely illegal, to one in which it is not only legal for recreational use, but also facilitated with government resources, has many implications in many realms. Advocates point to significant gains in the social justice arena and the relative safety of […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast- Immune-related adverse events from checkpoint inhibitors https://emcrit.org/pulmcrit/checkpoint/ https://emcrit.org/pulmcrit/checkpoint/#respond Wed, 19 Dec 2018 13:40:38 +0000 http://emcrit.org/?p=456183 If you haven't started seeing these yet, you will soon.  Checkpoint inhibitors are a form of immunotherapy being used for an increasingly broad range of malignancies.  They cause a diverse range of adverse events, due to releasing uncontrolled autoimmune hyperactivity.  Clinically this can mimic just about any rheumatologic condition.  Fortunately these events are quite treatable.  However, a high index of suspicion and prompt therapy is important.  

EMCrit Project by Josh Farkas.

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PulmCrit- Rant: Antimicrobial exposure and risk of delirium https://emcrit.org/pulmcrit/antibiotics-delirium/ https://emcrit.org/pulmcrit/antibiotics-delirium/#comments Mon, 17 Dec 2018 13:00:59 +0000 http://emcrit.org/?p=456119 This paper slipped across my twitter feed over the weekend.  It was a bit disquieting to see that it was getting a lot of attention, despite being a methodological train wreck (seriously, MedTwitter, where’s the skepticism??).  This post will briefly walk through some of the main flaws.  There will be a bit of pharmacology, a modicum of methodology, and a lot of ranting.  

EMCrit Project by Josh Farkas.

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EMCrit 238 – Medical Error Epidemic Craziness with G. Gianoli https://emcrit.org/emcrit/medical-error-epidemic-craziness/ https://emcrit.org/emcrit/medical-error-epidemic-craziness/#comments Wed, 12 Dec 2018 16:43:58 +0000 http://emcrit.org/?p=452087 EMCrit 238 - Medical Error Epidemic Craziness with G. Gianoli. Medical Error is the 3rd leading cause of death in the US--or is it?

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/medical-error-epidemic-craziness/feed/ 6 EMCrit 238 - Medical Error Epidemic Craziness with G. Gianoli. Medical Error is the 3rd leading cause of death in the US--or is it?
You and your brethren are the 3rd leading cause of death in the United States. Medical error is rampant, why are you not doing anything about this problem?
How many times have you heard these statistics and others like them? How many times have you been berated by patient safety experts using these very statistics as their foundation and their whip. Have you ever wondered how these statistics could possibly be true when it doesn't jibe at all with your day-to-day experience.

I know I have wondered...

Today, we get to the bottom of this craziness.
Gerard Gianoli, MD
He did an internship in General Surgery and an internship in Pediatrics. Following a residency in Otolaryngology- Head and Neck Surgery, he completed a fellowship in Otology, Neurotology and Skull Base Surgery at the Michigan Ear Institute. He was a full-time Associate Professor at Tulane Medical School until July 2000 when he joined Ear and Balance Institute. He still maintains a Clinical Associate Professor appointment at Tulane in both the Department of Otolaryngology-Head and Neck Surgery and the Department of Pediatrics. He has published and lectured extensively in the field of Neurotology and serves on multiple Editorial Review Boards for the fields of Neurotology and Otolaryngology.
Dr. Gianoli's Two Pieces on the Medical Error Studies

* Medical Error Hysteria1
* Unreliable Research on Error-Related Hospital Deaths in America - Gianoli and Dunn2

The Makary and Daniel article

* From the BMJ

More...

* Additional reanalysis from Shojania

Now on to the Podcast...





1.
Gianoli G. Medical Error Epidemic Hysteria. Am J Med. 2016;129(12):1239-1240. [PubMed]




2.
Gianoli G. Unreliable Research on Error-Related Hospital Deaths in America. JPANDS. 2016;21(4):104-108. http://jpands.org/vol21no4/gianoli.pdf.



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Scott D. Weingart, MD FCCM clean 17:09
IBCC chapter & cast- Adrenal crisis https://emcrit.org/pulmcrit/adrenal-crisis/ https://emcrit.org/pulmcrit/adrenal-crisis/#comments Wed, 12 Dec 2018 13:00:27 +0000 http://emcrit.org/?p=456002 Adrenal crisis is a can't-miss diagnosis.  Prompt identification and proper management will generally lead to rapid improvement.  The most important aspect is maintaining a high index of suspicion.  When in doubt, start empiric therapy first and ask questions later. The IBCC chapter is located here. The podcast & comments are below. Follow us on iTunes

EMCrit Project by Josh Farkas.

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