EMCrit Project https://emcrit.org Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Fri, 24 May 2019 18:24:07 +0000 en-US hourly 1 https://wordpress.org/?v=5.2.1 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 Overdiagnosis of uncomplicated pericarditis often leads to more harm than good https://emcrit.org/emcrit/pericarditis-ecg/ https://emcrit.org/emcrit/pericarditis-ecg/#comments Fri, 24 May 2019 11:00:57 +0000 https://emcrit.org/?p=461290 On waste basket diagnoses - Pericarditis

EMCrit Project by Pendell Meyers.

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PulmCrit: Neutrophil-Lymphocyte Ratio (NLR): Free upgrade to your WBC https://emcrit.org/pulmcrit/nlr/ https://emcrit.org/pulmcrit/nlr/#comments Thu, 23 May 2019 15:55:12 +0000 https://emcrit.org/?p=462290 introduction The neutrophil/lymphocyte ratio (NLR) has been gaining increasing attention across many fields of medicine within the past five years.  Currently, there are 2,230 publications about this in PubMed, mostly within the past few years.  This post will attempt to create a framework for understanding this ratio. overview definition & physiology The NLR is simply […]

EMCrit Project by Josh Farkas.

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Tox and Hound – Check Yourself https://emcrit.org/toxhound/check-yourself/ https://emcrit.org/toxhound/check-yourself/#comments Mon, 20 May 2019 14:21:21 +0000 https://emcrit.org/?p=462258 by Andrew Stolbach The history of cancer therapy is entwined with the history of the 20th and 21st centuries. Scientific discovery does not occur in a historical vacuum. The swirl of world events does not stop outside the laboratory. In 1910, as Viennese researchers Ernest Freund and Gisa Kaminer published observations that some substance in […]

EMCrit Project by Tox & Hound.

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PulmCrit: Validation of test-dose strategy for beta-lactam allergies https://emcrit.org/pulmcrit/test-dose/ https://emcrit.org/pulmcrit/test-dose/#respond Mon, 20 May 2019 11:57:49 +0000 https://emcrit.org/?p=462074 Background Kimberly Blumenthal and colleagues at the Massachusetts General Hospital have been performing groundbreaking work on beta-lactam allergies.  Their work forms the foundation for much of the IBCC chapter on beta-lactam allergies (you might want to read it before this post, but if you don't have time, a one-minute synopsis is below). One fundamental technique […]

EMCrit Project by Josh Farkas.

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EMCrit Podcast 247 – The Dissociated Awake Intubation with my buddy, Ketamine https://emcrit.org/emcrit/dissociated-awake-intubation/ https://emcrit.org/emcrit/dissociated-awake-intubation/#comments Thu, 16 May 2019 17:09:12 +0000 https://emcrit.org/?p=461902 All the dope on Dissociated Awake Intubation using Ketamine

EMCrit Project by Scott Weingart.

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A few days ago I posted George Kovacs' thoughts on the matter.

* George Kovacs on KFI

This was in response to a blog post by frenemy of the show and brilliant airway tactician, Reub Strayer.

* Ketamine-Only Breathing Intubation (KOBI)

What is Dissociated Awake Intubation?
I coined this term to describe the administration of a dissociating dose of ketamine to allow a patient to be intubated for many of the same circumstances as the traditional topical awake approach.

This is theoretically distinct from the idea of using ketamine in a sedative-only intubation. The two ideas are separated by the intent, with the former subbing for a topical awake and the latter for a RSI, in systems where for whatever reason, paralytic can be used. In practice, they look the same--it is often the users that look different.

Kovacs has used the term ketamine facilitated intubation to encompass both uses. This post and podcast only deal with dissociated awake.
Awake Intubation Posts

* Emergency Awake Topicalized (EAT) Intubation – An Awake Intubation Update
* Podcast 194 – Definitive Emergent Awake Intubation with George Kovacs

 Why Awake Intubation?
If an airway is predicted to be difficult, consider an awake approach. This predicted difficulty could be an anatomic. It could also be physiological: namely Hemodynamics Kills, Oxygenation Kills, or pH Kills. When there is a combination of two or three of these elements, awake becomes almost a must.
Awake vs. RSI
RSI and awake are tradeoffs

* RSI gives you the easiest laryngoscopy/tube delivery at the expense of safe time for intubation
* Awake gives you a markedly harder laryngoscopy/tube delivery rewarded by a markedly extended safe intubation time

You must be a much better intubator to perform an awake laryngoscopy and tube delivery.
Topicalized vs. Dissociated Awake

In some cases you will try topical first, and then when the pt won't cooperate or you can't adequately topicalize, that will push you to dissociation. However, there are definitely a group of patients who I will choose primary dissociated awake. It comes down to cognitive bandwidth.
Nuts and Bolts of the Technique

* Give small aliquots of ketamine every 15 sec. or so until dissociation (25 mg at a time
* Have everything ready for RSI and failed airway, including paralytics prepared and ready before first dose of ketamine
* I still topicalize

Awake Intubation from George's Online Textbook

Kovacs AIME Airway Textbook (Infinity Edition) - Awake Intubation Chapter)
Now on to the Podcast...]]>
Scott D. Weingart, MD FCCM clean 36:47
IBCC chapter & cast: Rhabdomyolysis https://emcrit.org/pulmcrit/rhabdo/ https://emcrit.org/pulmcrit/rhabdo/#comments Thu, 16 May 2019 11:42:08 +0000 https://emcrit.org/?p=462168 Before writing this chapter I though I understood rhabdomyolysis fairly well.  I had treated many cases, read about it in a few books, and heard a lecture or two on it.  However, writing this chapter has forced me to realize that I didn't really understand rhabdo well at all.  This disease is generally poorly understood, […]

EMCrit Project by Josh Farkas.

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Tox and Hound – U(ds) and I https://emcrit.org/toxhound/uds-and-i/ https://emcrit.org/toxhound/uds-and-i/#respond Mon, 13 May 2019 17:33:18 +0000 https://emcrit.org/?p=462060 by Howard Greller Recently, I’ve moved offices, and came across a number of old letters. A lot of it was just regular business stuff (e.g., credentialing packets, requests for privileges, a metric ton of menus, etc.), but there was a significant amount of correspondence as well, including some letters of a personal nature. In lieu […]

EMCrit Project by Tox & Hound.

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EMCrit – George Kovacs on Ketamine-Facilitated Intubation (KFI) https://emcrit.org/emcrit/ketamine-facilitated-intubation/ https://emcrit.org/emcrit/ketamine-facilitated-intubation/#comments Fri, 10 May 2019 22:12:52 +0000 https://emcrit.org/?p=462001 Frenemy of the show, Reub Strayer recently posted on a technique he calls Ketamine Only Breathing Intubation (KOBI). This is similar to the technique we have called dissociated awake intubation here at EMCrit. Within Reub's post was a 9-minute video and an excellent, recent WJEM review article–both are well worth checking out. This sparked a […]

EMCrit Project by Scott Weingart.

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The Case of the Magician’s Sleight https://emcrit.org/emnerd/the-case-of-the-magicians-sleight/ https://emcrit.org/emnerd/the-case-of-the-magicians-sleight/#comments Fri, 10 May 2019 01:07:48 +0000 https://emcrit.org/?p=461994 Since the earliest trials examining the efficacy of tPA for acute ischemic stroke there has been a tendency to play it fast and loose with the scientific method. The results of the landmark NINDS-2 trial (1), a moderate sized RCT, with a tenuously positive primary outcome (Fragility Index of 3), were never validated. The results […]

EMCrit Project by Rory Spiegel.

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IBCC chapter & cast: hypophosphatemia and hyperphosphatemia https://emcrit.org/pulmcrit/phos/ https://emcrit.org/pulmcrit/phos/#respond Thu, 09 May 2019 12:14:45 +0000 https://emcrit.org/?p=461971 Phosphate is the forgotten electrolyte of critical care.  Unlike other electrolytes, phosphate doesn't participate in the generation of electrochemical gradients (like calcium, magnesium, and potassium) or govern tonicity (like sodium).  Thus, moderate perturbations in phosphate are generally asymptomatic.  However, phosphate does participate in many essential cellular processes, so true intracellular hyphophosphatemia can cause severe symptoms.  […]

EMCrit Project by Josh Farkas.

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PulmCrit: Checkpoint inhibitors… for septic shock?? https://emcrit.org/pulmcrit/checkpoint-inhibitors-sepsis/ https://emcrit.org/pulmcrit/checkpoint-inhibitors-sepsis/#comments Mon, 06 May 2019 13:13:21 +0000 https://emcrit.org/?p=461693 Background Septic shock is generally conceptualized as a state of pathological immune hyperactivity.  Consequently, decades of work on immunomodulation in sepsis have focused on immunosuppressive medications (e.g. steroid, TNF-inhibitors, IL-1 inhibitors).  Although most of these interventions haven’t worked, steroid offers some benefits and IL-1 receptor antagonism shows promise for a subset of patients.1 The natural […]

EMCrit Project by Josh Farkas.

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EMCrit 246 – Philosophical & Psychological Diversions Part I – Liberterian Free Will, Blame and Shame https://emcrit.org/emcrit/free-will/ https://emcrit.org/emcrit/free-will/#comments Thu, 02 May 2019 19:15:27 +0000 http://emcrit.org/?p=452677 A swerve from typical content

EMCrit Project by Scott Weingart.

https://emcrit.org/emcrit/free-will/feed/ 40 A swerve from typical content
This Article is a Must Read if you Found this Episode on Free Will Interesting
The Lucretian Swerve
While 1% of this episode may be independent thinking, the rest was surely based on influences too countless to cite. Some that clearly remain foremost as inspiration are the article above, Dan Dennett's work, Sam Harris' book, the book, Four Views on Free Will, and all by poor undergrad professors that had to put up with the utter annoyance of my stubbornness.
Image by Narcournus




Scott D. Weingart, MD FCCM clean 21:10
IBCC chapter & cast: The myth of contrast nephropathy https://emcrit.org/pulmcrit/contrast/ https://emcrit.org/pulmcrit/contrast/#comments Thu, 02 May 2019 10:00:46 +0000 https://emcrit.org/?p=461794 Does contrast nephropathy exist?  Vigorous debate has been ongoing about this dating back to 2013.1  Hundreds of studies on the topic ultimately reveal no convincing evidence that contrast nephropathy exists.  However, it's unethical to perform a prospective RCT, so it's impossible to ever prove this.  This has left us in an evidentiary limbo – we […]

EMCrit Project by Josh Farkas.

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Tox and Hound – Unconscious Uncoupling – Managing pH in Salicylate Overdoses https://emcrit.org/toxhound/phinasa/ https://emcrit.org/toxhound/phinasa/#comments Tue, 30 Apr 2019 14:34:14 +0000 https://emcrit.org/?p=461772 by Dan Rusyniak When Gwyneth Paltrow “consciously uncoupled” from Chris Martin, I immediately thought of mitochondria. Why mitochondria? For one because mitochondria are the favorite organelle of toxicologists (sorry, sarcoplasmic reticulum . . .). And second, because I am fascinated by drugs that uncouple oxidative phosphorylation. There are lots of toxins that target mitochondria. There […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast – Endocarditis https://emcrit.org/pulmcrit/endo/ https://emcrit.org/pulmcrit/endo/#respond Thu, 25 Apr 2019 11:54:59 +0000 https://emcrit.org/?p=461662 Endocarditis is a classic disease of emergency medicine, inpatient medicine, and critical care.  The opioid epidemic has caused a surge of endocarditis diagnoses, reminding us of the myriad ways that this disease can present itself. 

EMCrit Project by Josh Farkas.

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EMCrit Podcast 245 – Tension Pneumothorax with Simon Leigh-Smith https://emcrit.org/emcrit/tension-pneumothorax/ https://emcrit.org/emcrit/tension-pneumothorax/#comments Wed, 24 Apr 2019 17:09:40 +0000 http://emcrit.org/?p=13623 Tension pneumothorax is actually 2 diseases

EMCrit Project by Scott Weingart.

https://emcrit.org/emcrit/tension-pneumothorax/feed/ 3 Tension pneumothorax is actually 2 diseases

Today, a topic about which you may already believe you know all you need to know--chances are you don't. What we were taught about tension pneumo by textbooks and trauma courses may not be right. To discuss tension pneumothorax, there is no better guest than...
Dr. Simon Leigh-Smith

Consultant in Emergency Medicine, Defence Medical Services & NHS Lothian, Surgeon Commander Royal Navy, Clinical Lead for Pre-Hospital Care and Medic 1

Simon graduated from Liverpool in 1990 and had a varied training / experience including Commando, Para, GP, Emergency Medicine and Pre-Hospital/Retrieval before Consultant appointment in 2006. He has worked in Liverpool, Plymouth, Edinburgh, Portsmouth, London, Sydney, Kuwait, Iraq, Belize, Norway, Antarctic, South Atlantic, Iraq and Afghanistan. He has a strong interest in Tension Pneumothorax, Human Factors in team working and the delivery of excellent pre-hospital care to major trauma and critical illness. He loves all the usual ‘adventure sports’ but after he sailed around Cape Horn his wife and 2 daughters were glad to hear that he no longer wanted to sail around the world! He tries to exercise his Hungarian Vizsla (dog) whilst mountain biking but often feels guilty leaving her behind to go for long road rides…..

Tension Pneumothorax is 2 Diseases rather than 1
Awake/Spontaneously Breathing Patients

* Purely hypoxemic
* No hypotension until just before collapse
* May have long periods of compensation (though can also progress in minutes)

Ventilated Patients

* Sudden, both resp and cardiovascular disease
* Will be hypoxemic and hypotensive

Classic Signs are Rubbish

* Tracheal deviation is unreliable
* Breath Sounds are unreliable
* Chest wall observation signs are variable
* Need to go with clinical suspicion or ultrasound, radiograph, or empiric decompression

More on the Perils of Needle Decompression

* EMCrit Needle vs. Knife II

A Countervailing View

Simon's Publications

* Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review1
* Tension pneumothorax - time for a re-think.
* Slides from Full Lecture

Additional Reading and Info

* Pulmonary Artery Pressures with Tension
* Decreased cardiac index as an indicator of tension pneumothorax in the ventilated patient

Roberts D, Leigh-Smith S, Faris P, et al. Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review. Ann Surg. 2015;261(6):1068-1078. https://www.ncbi.nlm.nih.gov/pubmed/25563887.

Scott D. Weingart, MD FCCM clean 31:24
Emergency Reflex Action Drills https://emcrit.org/emcrit/emergency-reflex-action-drills-2/ https://emcrit.org/emcrit/emergency-reflex-action-drills-2/#respond Wed, 24 Apr 2019 01:37:40 +0000 https://emcrit.org/?p=461634     This is an update to a post that I put up last year on something we call Emergency Reflex Action Drills.  This talk was given at the national Critical Care Transport Medicine Conference 2019.  For a more detailed description of elements discussed in the talk, as well as the references, check out the […]

EMCrit Project by Mike Lauria.

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PulmCrit- Why most diagnostic procedures aren’t beneficial https://emcrit.org/pulmcrit/diagnostic-procedures/ https://emcrit.org/pulmcrit/diagnostic-procedures/#comments Mon, 22 Apr 2019 11:00:54 +0000 https://emcrit.org/?p=461545 We often assume that diagnostic procedures will help patients.  A lot of training goes into learning how to do these procedures.  Procedures are dramatic.  We like performing them.  Patients are impressed, perceiving that we are “doing” something for them.  Everything is awesome.However, when strict evidence-based medicine is applied to procedures, they are often less impressive. 

EMCrit Project by Josh Farkas.

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IBCC chapter: VT storm https://emcrit.org/pulmcrit/storm/ https://emcrit.org/pulmcrit/storm/#comments Thu, 18 Apr 2019 20:05:12 +0000 https://emcrit.org/?p=461449 VT storm refers to recurrent episodes of VT/VF.  Although any individual episode of VT can be broken, the overall process of recurrent arrests (or ICD shocks) creates a vicious cycle.  Aggressive management is required with intubation, deep sedation, antiarrhythmics, and sympatholysis.  Given the rarity of this condition, it's difficult to obtain high-level evidence or extensive experience. 

EMCrit Project by Josh Farkas.

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EMCrit Podcast 244 – Incredibly Important Wrinkles to Titrated Vasopressors during CPR in Cardiac Arrest https://emcrit.org/emcrit/dbp-cpr/ https://emcrit.org/emcrit/dbp-cpr/#comments Mon, 15 Apr 2019 14:10:01 +0000 https://emcrit.org/?p=460878 We've been doing it all wrong--mysteries solved thanks to PO Berve

EMCrit Project by Scott Weingart.

https://emcrit.org/emcrit/dbp-cpr/feed/ 16 We've been doing it all wrong--mysteries solved thanks to PO Berve

In episode 130 of the podcast and in many subsequent discussions, I have advocated for femoral-artery-monitoring during cardiac arrest to allow titrated use of vasopressors. Many of my colleagues in the advanced resuscitation community have a similar practice. In 2013, the AHA has released an advanced practice guideline recommending the same practice.1


What if the diastolic blood pressure number shown on the monitor is the WRONG PRESSURE. That is the contention of our guest today:

It seems the machine picks the DBP that is the lowest point between systoles. This works well with waveforms generated by the normal cardiac compression. During CPR, however the lowest point (decompression phase nadir) actually represents the reformation of the aortic outflow tract after it has been compressed. This generates a brief negative pressure which can give extremely low pressures. If you use this as your DBP you will be steered in exactly the wrong direction--the better the cpr and the more pronounced the vascular tone, the lower this number will be.

In the arterial wave form image above, Point A is a DBP of zero. This is the number that will appear on the monitor; this number can actually be negative. In the past, I would be rezeroing the transducer thinking it must be in error. And when I spoke about refractory vasoplegia, it was because of this number. What we need to be looking at is Point B, the point just before the systolic upstroke--this is the true DBP to titrate your vasopressors according to PO. The better the CPR and the higher the vasomotor tone, the lower Point A and the higher Point B will be. So as we are doing better, we will see lower and lower DBPs if we go by the displayed numbers.

Here is a normal waveform from an actual beating heart as contrast:

You must visualize the waveform rather than looking at the computer-generated DBP

* Change displayed waveforms to 10 sec. if possible
* Auto-Wave (match the top and bottom of the scale to the actual waveform parameters) to make the waveforms as big as possible
* If your machine has a line that can be set to a pressure, put it at 40 mm Hg and then just look to see if the beginning of the systolic upstroke is above this line

The Full Lecture from the Big Sick
ScanFOAM has an amazing post with PO's full lecture, slides, and all the references from the lecture.

* PO Berve on Waveforms during Cardiac Arrest from scanFOAM

The Paradis et al. Papers

* 1989 Paper2
* 1990 Paper3

Superimposed Aortic and Right Atrial Waveforms

Note that the CVP and arterial waveforms look almost identical--you cannot differentiate arterial versus venous placement with waveforms alone.
The period of diastolic filling in the late decompression phase is shown below:

Identical Waves with the AutoPulse

Additional Information

* Review Article on where to measure DBP during CPR4
* Understanding Arterial Pressure5
* Experimental Simultaneous Waveforms on Swine6
* Case Report7

We screw up ETCO2 as well

* More from PO on this topic coming soon...

Now on to the Podcast...

Scott D. Weingart, MD FCCM clean 26:21
The Dantastic Mr. Tox & Howard – S02E09 – The Ascetic Arachnid https://emcrit.org/toxhound/s02e09-ascetic-arachnid/ https://emcrit.org/toxhound/s02e09-ascetic-arachnid/#respond Fri, 12 Apr 2019 16:26:12 +0000 https://emcrit.org/?p=461206 NOT RECLUSE with Dr. Rick Vetter Join Dan (@drusyniak) &Howard (@heshiegreshie) as they speak with Dr. Rick Vetter about all things brown recluse, why you should always inspect your packages very, very carefully, and why Howard will never move to Kansas. Delicious Links The USPS should be known as “The Fearless” . . . Arachnids […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast: Metformin-induced lactic acidosis, et al. https://emcrit.org/pulmcrit/metformin/ https://emcrit.org/pulmcrit/metformin/#comments Thu, 11 Apr 2019 10:00:26 +0000 https://emcrit.org/?p=461235 Metformin poisoning and lactic acidosis has always been murky.  For years there was debate about whether metformin-induced lactic acidosis exists (short answer:  it obviously does).  However, for an individual patient, it can still be confusing sorting out the contribution of metformin to their critical illness.  A recent re-definition of the condition clarifies things a bit, but substantial confusion persists regarding how to diagnose and treat these patients.  

EMCrit Project by Josh Farkas.

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PulmCrit- Extracorporeal CO2 removal: Putting the cart ahead of the horse? https://emcrit.org/pulmcrit/hypercapnia/ https://emcrit.org/pulmcrit/hypercapnia/#comments Mon, 08 Apr 2019 09:56:10 +0000 https://emcrit.org/?p=461145 Recently the concept of extracorporeal CO2 removal has become somewhat popular, with a goal of facilitating ultra low-tidal volume ventilation.  Might there be other means to achieve the same goal?  Let’s start with some basic concepts of mechanical ventilation… Fundamental unanswered questions Permissive hypercapnia refers to the concept of allowing the pCO2 level to increase […]

EMCrit Project by Josh Farkas.

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Tox and Hound – Fellow Friday – Rapid Collapse and Anaphylactoid Reactions from Rattlesnake Bites https://emcrit.org/toxhound/ff-rapid-collapse-rattlesnake/ https://emcrit.org/toxhound/ff-rapid-collapse-rattlesnake/#comments Fri, 05 Apr 2019 23:31:32 +0000 https://emcrit.org/?p=461059 by Steve Curry, M.D. Banner – University Medical Center Phoenix University of Arizona College of Medicine – Phoenix Phoenix, AZ @SteveCurryMD It’s early March in Phoenix and we are well into the rattlesnake bite season. It is estimated there are about 350 to 400 rattlesnake bites annually in Arizona, which is pretty tiny compared to […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast: Allergies to beta-lactam antibiotics https://emcrit.org/pulmcrit/penicillin/ https://emcrit.org/pulmcrit/penicillin/#comments Thu, 04 Apr 2019 11:39:50 +0000 https://emcrit.org/?p=460984 Emerging evidence shows that there is no such thing as a "penicillin allergy" or "cephalosporin allergy."  Instead, cross-allergic reactions are restricted to much smaller groups of antibiotics that share greater structural similarity.  This opens the door to using beta-lactam antibiotics safely in patients who have had an allergic reaction to one or more of these drugs.

EMCrit Project by Josh Farkas.

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Tox And Hound – In Defense of Case Reports https://emcrit.org/toxhound/defense-case-report/ https://emcrit.org/toxhound/defense-case-report/#comments Mon, 01 Apr 2019 15:32:52 +0000 https://emcrit.org/?p=460764 by David Juurlink I’ve been attending clinical toxicology conferences since NACCT 1999 in La Jolla, California. It’s impossible to attend one of these meetings without hearing a speaker (or, after a lecture, someone at the microphone with his own little speech cleverly disguised as a question) utter the words “There’s no evidence …”, usually in […]

EMCrit Project by Tox & Hound.

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Tox and Hound – Happy Birthday! https://emcrit.org/toxhound/happybirthday/ https://emcrit.org/toxhound/happybirthday/#respond Mon, 01 Apr 2019 15:28:27 +0000 https://emcrit.org/?p=460954 (to the tune of Happy Birthday) Woof woof woof woof bark bark. Woof woof woof woof bark bark. Woof woof woof woof bark bark bark. Woof woof woof woof bark bark. One year since the launch of this site, and we couldn’t be more excited for year two. Any suggestions, comments or criticisms? Let us […]

EMCrit Project by Tox & Hound.

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EMCrit Podcast 243 – The COACT Trial on Early vs. Delayed Cath after Cardiac Arrest without STEMI https://emcrit.org/emcrit/coact-trial/ https://emcrit.org/emcrit/coact-trial/#comments Sun, 31 Mar 2019 20:39:27 +0000 https://emcrit.org/?p=460927 New evidence on who needs to go to lab after cardiac arrest

EMCrit Project by Scott Weingart.

https://emcrit.org/emcrit/coact-trial/feed/ 2 New evidence on who needs to go to lab after cardiac arrest
Hot off the press is the COACT trial randomizing patients to immediate vs. delayed cardiac catheterization after cardiac arrest. I had this on my list to do a 'cast on, but EMCrit Team Member Felipe Teran beat me to it. He interviews past show guest and the lead author of the editorial on the paper, Ben Abella. The trial only included patients with an initial shockable rhythm and they were still unconscious. STEMIs went right to the lab.

* Actual Paper1
* Editorial2

This comes right at the heels of the AHA statement by Yannopoulos et al. recommending a more aggressive stance on immediate cath.3
ResusTEE Course

Easily the best resuscitative TEE/TOE course I have ever seen. Just pure goodness.
Use the Code:
to get an EMCrit Discount

London Course (April 27)
Montreal Course (May 21)

Now on to the Podcast...

Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. N Engl J Med. March 2019. doi:10.1056/nejmoa1816897

Abella BS, Gaieski DF. Coronary Angiography after Cardiac Arrest — The Right Timing or the Right Patients? N Engl J Med. March 2019. doi:10.1056/nejme1901651

Yannopoulos D, Bartos JA, Aufderheide TP, et al. The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation. 2019;139(12). doi:10.1161/cir.0000000000000630

Scott D. Weingart, MD FCCM clean 21:26
IBCC chapter & cast: Preeclampsia & HELLP syndrome https://emcrit.org/pulmcrit/preeclampsia/ https://emcrit.org/pulmcrit/preeclampsia/#comments Sat, 30 Mar 2019 12:18:48 +0000 https://emcrit.org/?p=460853 Preeclampsia is among the most commonly encountered obstetric emergencies.  Definitions and optimal therapies have changed significantly over the past few years.  Although specialists in Obstetrics will invariably be involved in these cases, all resuscitationists need to have a firm grasp of this topic. The optimal therapies for preeclampsia remain controversial.  For example, the International Society […]

EMCrit Project by Josh Farkas.

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Tox and Hound – Back Alley Beauty https://emcrit.org/toxhound/back-alley-beauty/ https://emcrit.org/toxhound/back-alley-beauty/#respond Mon, 25 Mar 2019 19:32:13 +0000 https://emcrit.org/?p=460807 By Sarah Shafer For reasons I Kardashian explain, trying to look “marvelous” is a big deal. In 2018, non-invasive cosmetic procedures, like botulinum injections, cosmetic fillers, chemical peels, and laser hair removal, were performed almost 16 million times. This, vastly outnumbered invasive procedures, such as breast augmentation and liposuction. With most things associated with wealth […]

EMCrit Project by Tox & Hound.

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PulmCrit- Nucleic acid microarrays streamline bacteremia management https://emcrit.org/pulmcrit/verigene/ https://emcrit.org/pulmcrit/verigene/#respond Mon, 25 Mar 2019 11:00:32 +0000 https://emcrit.org/?p=460754 Verigene is a nucleic acid micro-array which can be used to provide rapid information about positive blood cultures.  The array detects genetic information which may reveal the genus/species of bacteria and the presence of various resistance genes.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Hypertensive emergencies https://emcrit.org/pulmcrit/hypertensive/ https://emcrit.org/pulmcrit/hypertensive/#comments Sat, 23 Mar 2019 11:00:02 +0000 https://emcrit.org/?p=460724 Hypertensive emergency is a fairly common cause of ICU admission.  Surprisingly little high-quality data is available to guide our management of these patients (e.g. optimal Bp target?  ideal rate of reduction?  need for arterial line?).  This chapter describes a reasonable strategy to these patients, focusing on the pharmacokinetics of various antihypertensives.  

EMCrit Project by Josh Farkas.

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EM Nerd-The Case of the Irregular Irregularity Continues https://emcrit.org/emnerd/em-nerd-the-case-of-the-irregular-irregularity-continues/ https://emcrit.org/emnerd/em-nerd-the-case-of-the-irregular-irregularity-continues/#comments Wed, 20 Mar 2019 14:08:07 +0000 https://emcrit.org/?p=460675 Very little about the management of atrial fibrillation is an emergency. And yet we in the Emergency Medicine community have embraced it as such. We gleefully bring to bear the full technological powers available to an Emergency Physician in our attempts to tame its irregular irregularity. Using this aggressive approach, we have proven ourselves quite […]

EMCrit Project by Rory Spiegel.

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Tox and Hound – The Sound of Silence https://emcrit.org/toxhound/sound-of-silence/ https://emcrit.org/toxhound/sound-of-silence/#comments Thu, 14 Mar 2019 17:36:24 +0000 https://emcrit.org/?p=460558 By Diane Calello In 2001, radio talk show host Rush Limbaugh announced to his listeners that he woke up one morning deaf in his right ear and that deafness had progressed to complete hearing loss over 4 months. A tentative diagnosis of autoimmune hearing loss was made, and he received cochlear implants, restoring his hearing. […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast: Abdominal Compartment Syndrome https://emcrit.org/pulmcrit/abdominal-compartment/ https://emcrit.org/pulmcrit/abdominal-compartment/#comments Thu, 14 Mar 2019 10:00:35 +0000 https://emcrit.org/?p=460536 Abdominal compartment syndrome can result from primary abdominal pathology (e.g. bowel obstruction), but it can also occur due to systemic inflammation combined with large-volume resuscitation.  As such, abdominal compartment syndrome is probably more frequent than generally perceived, functioning as an occult driver of multi-organ failure.  Treatment is based upon physiological properties, involving many therapies aside from simply opening the abdomen. 

EMCrit Project by Josh Farkas.

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EM Nerd-The Case of the Conspicuous Conclusion https://emcrit.org/emnerd/em-nerd-the-case-of-the-conspicuous-conclusion/ https://emcrit.org/emnerd/em-nerd-the-case-of-the-conspicuous-conclusion/#comments Tue, 12 Mar 2019 20:55:38 +0000 https://emcrit.org/?p=460509 The process of rapid sequence induction (RSI) often forces the clinician to choose between two conflicting priorities. Torn between maintaining a safe level of oxygen, rendering the patient apneic, and limiting the amount of positive pressure ventilatory support given prior to obtaining a secure airway in the hopes of minimizing the risk of aspiration. Traditionally […]

EMCrit Project by Rory Spiegel.

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PulmCrit- DEXACET: Four grams of acetaminophen a day keeps the delirium away? https://emcrit.org/pulmcrit/dexacet/ https://emcrit.org/pulmcrit/dexacet/#comments Mon, 11 Mar 2019 10:11:40 +0000 https://emcrit.org/?p=460458 For decades, acetaminophen has been regarded as the first rung of the analgesic ladder.  It has a nearly unparalleled risk/benefit profile when dosed correctly (it’s not tremendously effective, but it is extraordinarily safe).  Theoretically, acetaminophen should be used very broadly among critically ill patients with pain.However, this isn’t the case. 

EMCrit Project by Josh Farkas.

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EMCrit Podcast 242 – ED Nephrology with Joel Topf aka KidneyBoy https://emcrit.org/emcrit/ed-nephrology/ https://emcrit.org/emcrit/ed-nephrology/#comments Sat, 09 Mar 2019 23:30:39 +0000 http://emcrit.org/?p=438940 ED Nephrology with the Kidney Boy, Joel Topf

EMCrit Project by Scott Weingart.

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Joel Topf is a nephrologist in Detroit working for St Clair Specialty Physicians. He is faculty for the Nephrology Fellowship at St John Providence.

Blog: PBFluids.com

Twitter: @Kidney_Boy

Co-creator: NephMadness, Co-creator: NephJC, Co-creator: DreamRCT
The Case

* Tweetorial on the Case
* Slides for the Case


* Topf thoughts on DDAVP in hypoNa
* DDAVP clamp in hyponatremia
* EMCrit Intro to Hyponatremia
* Curbsiders Hyponatremia Episode
* IBCC Hyponatremia
* Taking control of severe hyponatremia with DDAVP

Joel admits elderly with Na < 130

* Make sure they are not DI and then replete their free water deficit
* Acetazolamide for Nephrogenic DI1
* Hypernatremia is a marker of poor quality ICU Care2
* EMCrit Hypernatremia Episode
* IBCC Hypernatremia

Joel's Furosemide dose is Cr x 20

* Curbsiders on HyperK with Joel
* EMCrit HyperK
* IBCC HyperK
* Recent RCT on Kayexalate3
* The odds ratio for death was 10 at a potassium of 5.5 to 6 mEq/L. It rose to 31 for potassium above 6!4

Who Needs RRT?

* Is A,E,I,O,U still the answer?


* Get Joel's Free Electrolyte and Acid Base Book

Now on to the Podcast...

Gordon CE, Vantzelfde S, Francis JM. Acetazolamide in Lithium-Induced Nephrogenic Diabetes Insipidus. N Engl J Med. 2016;375(20):2008-2009. doi:10.1056/nejmc1609483

Polderman K, Schreuder W, Strack van, Thijs L. Hypernatremia in the intensive care unit: an indicator of quality of care? Crit Care Med. 1999;27(6):1105-1108. [PubMed]

Lepage L, Dufour A-C, Doiron J, et al. Randomized Clinical Trial of Sodium Polystyrene Sulfonate for the Treatment of Mild Hyperkalemia in CKD. Clinical Journal of the American Society of Nephrology.]]>
Scott D. Weingart, MD FCCM clean 1:05:38
Tox and Hound – To Bind or Not To Bind https://emcrit.org/toxhound/bindornot/ https://emcrit.org/toxhound/bindornot/#comments Thu, 07 Mar 2019 22:11:17 +0000 https://emcrit.org/?p=460387 by Jeanna Marraffa If you’re the gambling type, then this post is for you! 50/50 are pretty good odds, right? Or are they not and that’s why I never win in Vegas? I digress . . . let’s get back to the poll. Fifty percent of people said that they wouldn’t give digoxin-Fab to a […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast: Myasthenic Crisis https://emcrit.org/pulmcrit/myasthenia/ https://emcrit.org/pulmcrit/myasthenia/#comments Thu, 07 Mar 2019 10:57:29 +0000 https://emcrit.org/?p=460346 Myasthenic crisis along the fault-line between neurology and critical care medicine.  This creates a potentially dangerous situation, wherein nobody is fully informed or wholly responsible for the patient. 

EMCrit Project by Josh Farkas.

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