EMCrit Project https://emcrit.org Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Mon, 22 Jul 2019 19:35:38 +0000 en-US hourly 1 https://wordpress.org/?v=5.2.2 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 The Dantastic Mr. Tox & Howard – S02E11 – Labs Before Lectures https://emcrit.org/toxhound/labs-before-lectures/ https://emcrit.org/toxhound/labs-before-lectures/#comments Mon, 22 Jul 2019 19:35:14 +0000 https://emcrit.org/?p=465639 A decade of toxicologic history with Dr. Howard McKinney, Jr. Join Dan (@drusyniak) &Howard (@heshiegreshie) as they turn on, tune in, and drop out with Dr. Howard McKinney, Jr. during the Summer of Love and the “Decade of Tox”. They’ll remind you to always know your chemist, round up your spotters, chill out in the […]

EMCrit Project by Tox & Hound.

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EMCrit Wee – Semper Vitae – GRM with Helen Perry https://emcrit.org/emcrit/emcrit-wee-semper-vitae-grm-with-helen-perry/ https://emcrit.org/emcrit/emcrit-wee-semper-vitae-grm-with-helen-perry/#respond Sat, 20 Jul 2019 16:52:15 +0000 https://emcrit.org/?p=462423 There is a group of clinicians operating on the front line of war zones with no other purpose than to save lives. Global Response Management's Helen Perry comes on the show to discuss their work. Their motto is semper vitae–always life. Their mission is to provide life saving emergency and prehospital care to those impacted […]

EMCrit Project by Scott Weingart.

https://emcrit.org/emcrit/emcrit-wee-semper-vitae-grm-with-helen-perry/feed/ 0 There is a group of clinicians operating on the front line of war zones with no other purpose than to save lives. Global Response Management's Helen Perry comes on the show to discuss their work. Helen Perry ACNP-BC, MSN, RN, CCRN, CEN Helen Perry ACNP-BC, MSN, RN, CCRN, CEN
Their motto is semper vitae--always life. Their mission is to provide life saving emergency and prehospital care to those impacted by war and conflict.
Find Global Response

* The website is www.global-response.org
* Instagram global.response

* Facebook
* Twitter @GRM_Global

We are always looking for qualified volunteers and we use Paramedics and above. EMTs are welcome to apply, but they may not be working in a clinical capacity due to World Health Organization minimum operating standards. We even need non-medical folks (social media marketing, finance, smart computer people, grant writers, etc.)
They are a registered not-for-profit (501c3) and their admin budget is super low. Please consider helping these folks.
Now on to the Wee...


Scott D. Weingart, MD FCCM clean 26:19
IBCC chapter – Hyperthermia & heat stroke https://emcrit.org/pulmcrit/hyperthermia/ https://emcrit.org/pulmcrit/hyperthermia/#comments Sat, 20 Jul 2019 00:54:17 +0000 https://emcrit.org/?p=465669 Since it looks like the United States is about to go into total meltdown from a heat wave, I dusted off the hyperthermia chapter.  This is a bit of an impromptu post, so we don't have a podcast to go along with it (we will record one eventually – Adam has more experience with the […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Alcohol Withdrawal https://emcrit.org/pulmcrit/etoh/ https://emcrit.org/pulmcrit/etoh/#respond Thu, 18 Jul 2019 11:07:35 +0000 https://emcrit.org/?p=463677 Below is a card from one of the first patients I treated for alcohol withdrawal.  He lingered in the hospital for days on various benzodiazepine regimens (including a lorazepam infusion), and eventually limped home on an oral chlordiazepoxide taper.  He wrote me a thank-you card days after leaving the hospital, but as you can see […]

EMCrit Project by Josh Farkas.

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EMCrit 251 – Philosophical & Psychological Diversions Part II – Naive Reality and the Fundamental Attribution Error https://emcrit.org/emcrit/philosophy-2/ https://emcrit.org/emcrit/philosophy-2/#comments Tue, 16 Jul 2019 17:17:09 +0000 https://emcrit.org/?p=461805 More Philosophical Ramblings...

EMCrit Project by Scott Weingart.

https://emcrit.org/emcrit/philosophy-2/feed/ 1 More Philosophical Ramblings...
In Part I of the philosophical diversions series, we discussed free will. Today, let's bring up some other thoughts:
Conscious Decisions
Consciousness by Annaka Harris

Podcast Episode
Naïve Realism
Perception isn't Reality

* Ross, L., & Ward, A. (1996). Naive realism in everyday life: Implications for social conflict and misunderstanding. In T. Brown, E. S. Reed & E. Turiel (Eds.), Values and Knowledge (pp. 103–135).

Fundamental Attribution Error
The RCM is Back in Stock

Now on to the Podcast...]]>
Scott D. Weingart, MD FCCM clean 25:28
Tox and Hound – Archery: The Official Sport of Medical Toxicology https://emcrit.org/toxhound/archery/ https://emcrit.org/toxhound/archery/#comments Mon, 15 Jul 2019 20:25:41 +0000 https://emcrit.org/?p=463595 A very special welcome to our newest hound, Dr. Trevonne Thompson! You can learn more about him here . . . by Trevonne Thompson Archery should be recognized as the official sport of medical toxicology. Medical Toxicology is, by my own estimation, an avant-garde specialty, and is arguably the best specialty in medicine. While its modern history, […]

EMCrit Project by Tox & Hound.

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Pulmcrit- Evidence Update: Phenobarbital in Alcohol Withdrawal https://emcrit.org/pulmcrit/phenobarb-sampler/ https://emcrit.org/pulmcrit/phenobarb-sampler/#comments Mon, 15 Jul 2019 11:38:26 +0000 https://emcrit.org/?p=463522 Over the past year, the five papers below were published regarding the use of phenobarbital in alcohol withdrawal. These studies aren’t massive, glittering multicenter RCTs (and, realistically, it’s dubious whether such a study will happen). However, these papers bring some unique and interesting perspectives to the table. This post will summarize them briefly - a bit like a sampler flight of beers (figure above).

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Ascending cholangitis & calculus cholecystitis (community-acquired biliary sepsis) https://emcrit.org/pulmcrit/biliary/ https://emcrit.org/pulmcrit/biliary/#comments Thu, 11 Jul 2019 10:40:42 +0000 https://emcrit.org/?p=463501 Biliary infection is a fairly common cause of septic shock (especially ascending cholangitis).  Evidence isn't terrific regarding exactly when and how interventions should be done to obtain source control (particularly among cholecystitis).  This chapter attempts to reach some clarity on the topic but honestly, it remains a bit murky.  

EMCrit Project by Josh Farkas.

https://emcrit.org/pulmcrit/biliary/feed/ 1
Tox and Hound – The Physostigma https://emcrit.org/toxhound/physostigma/ https://emcrit.org/toxhound/physostigma/#respond Tue, 09 Jul 2019 16:23:08 +0000 https://emcrit.org/?p=463458 A very special welcome to our newest hound, Dr. Jon Cole! You can learn more about him here . . . by Jon Cole It’s a busy day in the ED. ICU beds are tight, ambulances keep coming, and triage grows at a seemingly exponential rate. Waiting for you are your first three patients, all of whom […]

EMCrit Project by Tox & Hound.

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Tox and Hound – Breastfeeding on Bup https://emcrit.org/toxhound/breastfeeding-bup/ https://emcrit.org/toxhound/breastfeeding-bup/#respond Fri, 05 Jul 2019 17:31:32 +0000 https://emcrit.org/?p=463276 A very special welcome to our newest hound, Dr. Christine Murphy! You can learn more about her here . . . by Christine Murphy Several months ago, I was taking care of an infant whose mother was terrified she would cause opioid withdrawal if she stopped breastfeeding. The mother was on medication assisted therapy (MAT) with buprenorphine, […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast – Clostridioides Difficile https://emcrit.org/pulmcrit/cdiff/ https://emcrit.org/pulmcrit/cdiff/#comments Thu, 04 Jul 2019 12:08:14 +0000 https://emcrit.org/?p=463258 Clostridioides (previously clostridium) difficile is an inescapable problem within the critical care arena.  This may arise as a nosocomial complication, in which case it is usually diagnosed early and treated successfully.  It may also be the primary cause of admission to the ICU, in which case it is generally more severe.  

EMCrit Project by Josh Farkas.

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Dual External Defibrillation: Close, but Not Touching by Mark Ramzy https://emcrit.org/emcrit/double-defibrillation/ https://emcrit.org/emcrit/double-defibrillation/#comments Wed, 03 Jul 2019 23:08:55 +0000 https://emcrit.org/?p=462818 The scoop on dual defibrillation

EMCrit Project by Guest Author.

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PulmCrit- Rigorous vs. lenient spontaneous breathing trials: The answer at last? https://emcrit.org/pulmcrit/psv8/ https://emcrit.org/pulmcrit/psv8/#comments Mon, 01 Jul 2019 10:43:34 +0000 https://emcrit.org/?p=463110 background There has long been debate about exactly how to design a spontaneous breathing trial.  If the trial is made too easy, then patients would be extubated before being ready (leading to re-intubation).  Alternatively, if the trial is too hard, that would prolong mechanical ventilation beyond the point of being beneficial.  The figure above shows […]

EMCrit Project by Josh Farkas.

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EMCrit Podcast 250 – The OMI Manifesto Lecture by Pendell Meyers https://emcrit.org/emcrit/emcrit-podcast-250-the-omi-manifesto-lecture-by-pendell-meyers/ https://emcrit.org/emcrit/emcrit-podcast-250-the-omi-manifesto-lecture-by-pendell-meyers/#comments Thu, 27 Jun 2019 19:15:55 +0000 https://emcrit.org/?p=462594 A video version of the rebellion's attempts to overthrow the STEMI Empire

EMCrit Project by Pendell Meyers.

https://emcrit.org/emcrit/emcrit-podcast-250-the-omi-manifesto-lecture-by-pendell-meyers/feed/ 8 A video version of the rebellion's attempts to overthrow the STEMI Empire

Pendell Meyers is attempting to change the paradigm of classifying MIs as STEMI vs. NSTEMI. An important first step in this attempt was his publishing the
OMI Manifesto
However, many folks just don't read, so here is a video version.

Ideas to Think About...

* False Negative Paradox
* Why did the term stemi equivalents not catch on?
* Why is there not currently a retrospective coding of missed occlusive MIs?

Please, please put your thoughts and comments below

Scott D. Weingart, MD FCCM clean 53:48 yes
IBCC chapter & cast – Fluid selection & pH-guided fluid resuscitation https://emcrit.org/pulmcrit/fluid/ https://emcrit.org/pulmcrit/fluid/#comments Thu, 27 Jun 2019 11:43:32 +0000 https://emcrit.org/?p=463075 Based on this polling data, 42% of you will hate this chapter.  It's a good thing I'm not running for president. Seriously though, fluid selection remains controversial.  This chapter presents an approach which makes sense physiologically and is supported by a substantial amount of animal and human data. 

EMCrit Project by Josh Farkas.

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Tox and Hound – Fear and Loathing in Alcohol Withdrawal https://emcrit.org/toxhound/fear-and-loathing-etoh/ https://emcrit.org/toxhound/fear-and-loathing-etoh/#comments Tue, 25 Jun 2019 19:34:44 +0000 https://emcrit.org/?p=463021 by Jeff Lapoint “I was not proud of what I had learned, but I never doubted that it was worth knowing.” Hunter S. Thompson I don’t know why I’ve been identifying with the works of Hunter S Thompson of late. It’s not because the political times seem eerily similar to that of 1972, nor because […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast: Hypercalcemia https://emcrit.org/pulmcrit/hypercalcemia/ https://emcrit.org/pulmcrit/hypercalcemia/#respond Thu, 20 Jun 2019 13:27:40 +0000 https://emcrit.org/?p=462906 Hypercalcemia isn't a particularly common cause of critical illness, but when encountered this requires immediate treatment.  Fortunately, advances in the treatment for hypercalemia have clarified how to do this safely and definitively.  Forced diuresis with furosemide has largely fallen by the wayside, simplifying fluid and electrolyte management.  The cornerstone of therapy is generally simultaneous initiation of calcitonin and an IV bisphosphonate.

EMCrit Project by Josh Farkas.

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PulmCrit- TEG for cirrhotic coagulopathy: Time for clinical implementation? https://emcrit.org/pulmcrit/teg-cirrhosis/ https://emcrit.org/pulmcrit/teg-cirrhosis/#comments Mon, 17 Jun 2019 12:22:45 +0000 https://emcrit.org/?p=462693 Introduction Traditional coagulation studies (especially the INR) fail miserably in cirrhosis.  Thromboelastography (TEG) is a superior approach for understanding the global balance of pro-coagulants versus anti-coagulants in these patients.  This isn’t anything particularly new – for example, it was explored in this post from 2015 (if you're not familiar with this concept already, it's explained […]

EMCrit Project by Josh Farkas.

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The Case of the False Imprisonment https://emcrit.org/emnerd/the-case-of-the-false-imprisonment/ https://emcrit.org/emnerd/the-case-of-the-false-imprisonment/#comments Sat, 15 Jun 2019 00:40:02 +0000 https://emcrit.org/?p=462823 In the FOAM community a great deal of time is spent discussing the appropriate manner of transitioning critically ill patients onto mechanical ventilation. A far larger portion of the practice of critical care is spent determining how best to liberate our patients from the ventilatory shackles with which we have bound them. The specifics of […]

EMCrit Project by Rory Spiegel.

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EMCrit 249 – You Can Either Learn or You Can Blame – Fixing the Morbidity and Mortality Conference with George Douros https://emcrit.org/emcrit/fixing-mm-conf/ https://emcrit.org/emcrit/fixing-mm-conf/#comments Thu, 13 Jun 2019 14:20:59 +0000 http://emcrit.org/?p=451726 How to make your M&M conference important and useful

EMCrit Project by Scott Weingart.

https://emcrit.org/emcrit/fixing-mm-conf/feed/ 3 How to make your M&M conference important and useful
You Can Either Learn or You Can Blame, You Can't Do Both
--Sydney Dekker
Steps Prior to the M&M
Find a Case
The standard referral paths (hospital reporting, pissed off administrators, mortalities) will happen automatically. But you also want to establish yourself as a Master of Whisperers. The way to get people to report cases is to inspire trust. You need to offer protection, establish clear patterns of non-putative motives, and show that you actually do something with the information reported.
Build a Thin Timeline
Comb the chart to build an initial time-line. This will only reflect events, but will offer little actual understanding of what took place.
Interview Primary Decision-Makers

* Dr. Douros asks lets them know he wants to meet over coffee and asks them to write up a 1 paragraph description of events.
* He sends out a Pre-Reading Sheet of what to expect.
* The goal is to find the inflection point where things diverted from optimal care
* Then to get to the point where the actions that occurred make sense
* Seek to Understand Local Rationality

* Knowledge at the time
* Focus at the time
* Goals at the time

* Goals of this interview overlap greatly with the skillset of a simulation debriefer. As such, check out Simulcast for amazing resources.

Build a Thick Timeline
Incorporate the results of the interview(s) into the timeline
Analyze for Systemic Problems and Brainstorm Solutions
Behavior must be judged as if the outcome is not known. If it was ok when things go right, it is ok when things go wrong.

Presenting the M&M
Dr. Douros does 2 cases in a one-hour block, 1 of them an M&M and the other a Safety & Success case (similar to the Amazing & Awesome Rounds).
Remind the group that this is about learning and identifying systemic problems, not about blame & shame.
Present the Thin and Thick Timelines

* Should take about 10 minutes.
* Exclude extraneous information
* The case can be presented by a Junior, but there needs to be a master facilitator at all sessions

Discuss the Case
~10-15 minutes
Probe for Systemic Problems and Solutions
~10-15 minutes
Send F/U Email with Lessons
To reinforce for those who attended and fill in those who did not
Recommended Resources

The Field Guide to Understanding 'Human Error'

This is the first go-to, a must read. It will change your vision of error.

Next, you can move on to another Dekker book:

clean 26:11
IBCC chapter & cast: Serotonin syndrome https://emcrit.org/pulmcrit/serotonin/ https://emcrit.org/pulmcrit/serotonin/#respond Thu, 13 Jun 2019 12:11:00 +0000 https://emcrit.org/?p=462777 Serotonin syndromes comes up a lot in critical care medicine.  Sometimes we are admitting patients because of a primary diagnosis of serotonin syndrome.  Other times we are afraid of causing serotonin syndrome ourselves, due to polypharmacy.  In both scenarios, there may be uncertainty regarding whether or not a patient has serotonin syndrome. This chapter explores […]

EMCrit Project by Josh Farkas.

]]> https://emcrit.org/pulmcrit/serotonin/feed/ 0 Tox and Hound – A Few Days on the Drug Circuit https://emcrit.org/toxhound/drug-circuit/ https://emcrit.org/toxhound/drug-circuit/#comments Wed, 12 Jun 2019 02:39:31 +0000 https://emcrit.org/?p=462747 by Jeanna Marraffa A 45-year-old male with history of cardiomyopathy has an out of hospital cardiac arrest. Resuscitative efforts were initiated pre-hospital and return of spontaneous circulation (ROSC) was achieved. However, upon arrival to the emergency department (ED), he was profoundly hypotensive with a blood pressure of 50/palp and a heart rate of 40 beats […]

EMCrit Project by Tox & Hound.

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Tox and Hound – In the Beginning https://emcrit.org/toxhound/in-the-beginning/ https://emcrit.org/toxhound/in-the-beginning/#comments Thu, 06 Jun 2019 14:15:24 +0000 https://emcrit.org/?p=462619 by Diane Calello Risk Assessment in Acetaminophen Toxicity In the beginning God created the heavens and the earth. Darkness covered the formless earth, wind swept over the waters. And God said, “Let there be acetaminophen”. And so it was. And it was good. Then man discovered acetaminophen and, realizing he was naked without it, covered […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast: Tick-borne infections https://emcrit.org/pulmcrit/tick/ https://emcrit.org/pulmcrit/tick/#comments Thu, 06 Jun 2019 12:45:20 +0000 https://emcrit.org/?p=462641 It's spring in Vermont... when a young intensivist's thoughts go from fancy to tick-borne diseases.  Climate shifts are causing an increase in tick-borne illnesses, such that these are now considered emerging infections in many areas (including the northeast United States and Canada).  These diseases can be extremely difficult to diagnose, as they will often present with a nonspecific flu-like illness and may subsequently progress to multi-organ failure.  Misdiagnosis of a tick-borne illness as bacterial septic shock would lead to inadequate treatment, as these diseases require specific antibiotic therapy (usually doxycycline).  This chapter focuses on diagnosis and empiric therapy for these very challenging infections.  

EMCrit Project by Josh Farkas.

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The Dantastic Mr. Tox & Howard – S02E10 – The Secret Diet of Pets https://emcrit.org/toxhound/s02e10-secret-diet-pets/ https://emcrit.org/toxhound/s02e10-secret-diet-pets/#respond Tue, 04 Jun 2019 13:34:12 +0000 https://emcrit.org/?p=462559 Exploring the World of Veterinary Toxicology with Dr. Ahna Brutlag Join Dan (@drusyniak) &Howard (@heshiegreshie) as they explore the world of veterinary toxicology with Dr. Ahna Brutlag, Director of Veterinary Services at the Pet Poison Helpline. Find out how the approach to the poisoned veterinary patient is both similar and different to our bipedal brethren. […]

EMCrit Project by Tox & Hound.

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EMCrit 248 – How to Teach Surgical Airways–you knows, Crics: The One-Hour Cricothyrotomy Course https://emcrit.org/emcrit/how-to-teach-surgical-airways/ https://emcrit.org/emcrit/how-to-teach-surgical-airways/#respond Tue, 04 Jun 2019 11:45:30 +0000 https://emcrit.org/?p=461198 Lessons learned from teaching hundreds of people to cric

EMCrit Project by Scott Weingart.

https://emcrit.org/emcrit/how-to-teach-surgical-airways/feed/ 0 Lessons learned from teaching hundreds of people to cric At the last SMACC, I yet again taught the surgical airway station of the airway workshop. I was joined with amazing faculty and together we taught 160 people our method of performing cricothyrotomy. We've been doing this for 4 years, but this past session was the first time it really felt just right. In this podcast, I want to go over some of the lessons learned and how they may contribute to your own self-training on surgical airway.


Each participant had their own 3-d printed model. This was absolutely crucial and a big difference from prior sessions.

Who Gets a Cric & Mental Prep

including a discussion of CricCon2

see this prior episode for more on CricCon

Finding the Membrane/Cut Site

Start Low, feel high

Laryngeal Handshake

We teach Rich's choke hold as a backup method​1–3​

* Practice_of_Ultrasound_Guided_Palpation_of_Neck

Build the Model

We used the same steps as in my how to practice crics video

Teaching the participants to build their own was hopefully encouragement to get their own model and practice each month.

All they need is:

* the 3D-printed model* Good gaffers tape* 4x4s* Plastic Bags

We had a few of the frova cric trainer holders, which would have been nice to use, but we didn't have enough for everybody, so we left them in the box.

Rapid Cycle Deliberate Practice (RCDP)

I learned about this teaching method from Alia Dharamsi at the amazing ResusTO conference. I also used the a modified version of her delphi-derived steps as a handout taped to each station.

Hear more from Alia

* Alia Dharamsi on Delphi-Study and RCDP

Alia Dharamsi

Steps of RCDP​4​

* Splitting Cases/Procedures into small segments* Micro-Debrief after each one* Add progressive challengesfrom Taras & Everett

* EMCrit-Modified Cric Steps* The Original Delphi Article


* Step-by-Step through the Procedure * Dominant Side Palpable Anatomy* Look-Up* Non-Dominant Side* Non-Palpable Anatomy / Cut and then spread to air* Under Stress

I was demonstrating up front with a video camera--this was huge as it allowed real-time correction with a much lower instructor to participant ratio. I could see a mistake, pause the group, and re-demonstrate proper technique for everyone.

Scott D. Weingart, MD FCCM clean 15:49
PulmCrit: Myth-busting the fluid bolus https://emcrit.org/pulmcrit/bolus/ https://emcrit.org/pulmcrit/bolus/#comments Mon, 03 Jun 2019 11:19:40 +0000 https://emcrit.org/?p=462518 For centuries, medical experts practiced bloodletting for a variety of ailments. This was widely believed to rid the body of evil humors. When patients didn’t respond well, this was believed to reflect an inadequate or delayed bloodletting. Practitioners competed to see who could partake in the most rapid and aggressive bloodletting.

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Hepatic Encephalopathy https://emcrit.org/pulmcrit/he/ https://emcrit.org/pulmcrit/he/#comments Thu, 30 May 2019 12:04:25 +0000 https://emcrit.org/?p=462465 Hepatic encephalopathy is a common cause of ICU admission, as well as a common complication of ICU admission for other indications (e.g. gastrointestinal hemorrhage).  At first the intubated patient with hepatic encephalopathy may seem a bit bewildering (will they ever wake up??).  However, an organized and aggressive strategy combined with some patience is generally sufficient […]

EMCrit Project by Josh Farkas.

https://emcrit.org/pulmcrit/he/feed/ 4
Tox and Hound – Sneaking into the Party https://emcrit.org/toxhound/sneak-in/ https://emcrit.org/toxhound/sneak-in/#comments Wed, 29 May 2019 08:11:48 +0000 https://emcrit.org/?p=462441 by Sarah Shafer How does a heart break? In the case of beta-blocker (BB) and calcium-channel blocker (CCB) overdose, it’s a lack of calcium. Calcium is essential to muscle contraction, allowing actin and myosin to interact so that the cell shortens. Without calcium, the myosin and actin are blocked from interacting, and the cell stays […]

EMCrit Project by Tox & Hound.

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CC Nerd-The Case of the Needless Blockade https://emcrit.org/emnerd/cc-nerd-the-case-of-the-needless-blockade/ https://emcrit.org/emnerd/cc-nerd-the-case-of-the-needless-blockade/#respond Fri, 24 May 2019 20:29:04 +0000 https://emcrit.org/?p=462352   A recent post on the EXTEND Trial stimulated a passionate debate regarding the use of adjusted analysis in RCTs. A number of of those partaking in this discussion argued feverishly for the use of adjusted analysis in RCTs, and made very strong arguments in favor of such methods. I argued that while adjusted analyses […]

EMCrit Project by Rory Spiegel.

https://emcrit.org/emnerd/cc-nerd-the-case-of-the-needless-blockade/feed/ 0
EMCrit – 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.

https://emcrit.org/emcrit/pericarditis-ecg/feed/ 5
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.

https://emcrit.org/pulmcrit/nlr/feed/ 4
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/#comments 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/#comments 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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