EMCrit Project https://emcrit.org Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Tue, 20 Oct 2020 01:08:16 +0000 en-US hourly 1 https://wordpress.org/?v=5.5.1 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 IBCC chapter & cast – Stress hyperglycemia in the ICU https://emcrit.org/pulmcrit/glucose/ https://emcrit.org/pulmcrit/glucose/#comments Mon, 19 Oct 2020 11:00:42 +0000 https://emcrit.org/?p=478783 Glycemic control in the ICU is a topic of perpetual controversy.  We've come full circle in the past 20 years – beginning with permissive hyperglycemia, then moving to tight control, and finally now moving back to permissive hyperglycemia.  The final answer remains unknown, but in the interim this chapter attempts to muddle through available evidence. […]

EMCrit Project by Josh Farkas.

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EMCrit 283 – Dexmedetomidine (Precedex) – You’d have to be Delirious Not to Use It https://emcrit.org/emcrit/dexmedetomidine/ https://emcrit.org/emcrit/dexmedetomidine/#comments Fri, 16 Oct 2020 15:50:00 +0000 http://emcrit.org/?p=458871 Dexmedetomidine (Precedex) - You'd have to be Delirious Not to Use It -

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/dexmedetomidine/feed/ 18 Dexmedetomidine (Precedex) - You'd have to be Delirious Not to Use It -
So this episode addresses a big gap in the EMCrit content, namely a discussion of the myriad uses of dexmedetomine. This is one of the primary agents I use for post-intubation sedation (PAD), but also for things like NIPPV sedation and procedural sedation.
Upsides of Dexmedetomine (Precedex)

* No respiratory depression
* Opioid sparing/analgesic effect
* Preserves Sleep Architecture
* Sympatholysis
* May be delirium-protective
* May be more hemodynamically stable than propofol
* Good for neurocritical care

Downsides of Dexmedetomidine

* Bradycardia
* Hypotension (especially when the pt is volume depleted)
* Cost (much less of an issue now that it is generic)
* Diuretic effect
* Slow onset
* Constipation

Useful for...

* Post-intubation sedation
* NIPPV sedation
* Procedural sedation
* Add-on to propofol

Other Stuff on EMCrit

* Podcast 115 – A New Paradigm for Post-Intubation Pain, Agitation, and Delirium (PAD)
* PulmCrit Wee- Extubating the agitated patient: dexmedetomidine vs. cowboy-style?
* Dexmedetomidine to facilitate noninvasive ventilation

 
Studies


The Effect of Propofol and Dexmedetomidine Sedation on Norepinephrine Requirements in Septic Shock Patients (Critical Care Medicine: February 2019 - Volume 47 - Issue 2 - p e89–e95)
https://www.ncbi.nlm.nih.gov/pubmed/21812509
https://www.ncbi.nlm.nih.gov/pubmed/27035758


Now on to the Podcast...]]>
Scott D. Weingart, MD FCCM 15:30
IBCC chapter & cast – Wernicke encephalopathy https://emcrit.org/pulmcrit/wernicke/ https://emcrit.org/pulmcrit/wernicke/#comments Wed, 14 Oct 2020 13:19:14 +0000 https://emcrit.org/?p=478709 Wernicke encephalopathy is important because it's surprisingly common, potentially debilitating, and fully treatable.  Some patients may present to the hospital due to Wernicke encephalopathy, while many others may develop this while in the ICU as an iatrogenic complication of criical care. The IBCC chapter is located 👉 here. The podcast & comments are below. Follow […]

EMCrit Project by Josh Farkas.

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NeuroEMCrit – Everything you wanted to know about Hyperosmolar agents for the Management of ICP and Cerebral Edema https://emcrit.org/emcrit/hyperosmolar-agents-icp-emergencies/ https://emcrit.org/emcrit/hyperosmolar-agents-icp-emergencies/#comments Sun, 11 Oct 2020 13:22:49 +0000 https://emcrit.org/?p=477774 Everything you wanted to know about Hyperosmolar agents for the Management of ICP and Cerebral Edema

EMCrit Project by Neha Dangayach.

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IBCC chapter & cast – Valproic Acid Intoxication https://emcrit.org/pulmcrit/valproate/ https://emcrit.org/pulmcrit/valproate/#comments Mon, 05 Oct 2020 11:00:56 +0000 https://emcrit.org/?p=478641 Valproic acid poisoning is fortunately uncommon.  However, this is a potentially lethal and rather complex intoxication.  Management spans the gamut from decontamination and dialysis, to various metabolic manipulations.  With an aggressive and organized approach, most patients will do extremely well. The IBCC chapter is located 👉 here. The podcast & comments are below. Follow us […]

EMCrit Project by Josh Farkas.

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EMCrit 282 – Hicks on the Labors of Trauma (Blunt) https://emcrit.org/emcrit/hicks-labors-trauma/ https://emcrit.org/emcrit/hicks-labors-trauma/#comments Wed, 30 Sep 2020 22:05:54 +0000 https://emcrit.org/?p=477505 Chris Hicks and I discussing the Labors of Trauma (Blunt edition), everything a trauma team leader needs on their radar screen.

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/hicks-labors-trauma/feed/ 2 Chris Hicks and I discussing the Labors of Trauma (Blunt edition), everything a trauma team leader needs on their radar screen. So a few weeks ago, I podcasted the Labors of Trauma, a comprehensive list of the responsibilities of a Trauma Team Leader.
EMCrit 278 - Labors of Trauma - Blunt Edition
I promised that I was going to do a part II with my co-conspirator, Chris Hicks.
Hick's Pre-Brief and Leave the Room Checklist


 


St. Mike's New Trauma Bays

Calcium

Ditzel RM Jr, Anderson JL, Eisenhart WJ, et al. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond?. J Trauma Acute Care Surg. 2020;88(3):434-439

New Hemostatic Resus Ratios

* Should we add calcium and fibrinogen to our ratios

New Name for the Pelvic Binder

* We should be calling these Trochanteric Binders

Now on to the Podcast...


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Scott D. Weingart, MD FCCM 38:27
IBCC chapter & cast – BRASH syndrome https://emcrit.org/pulmcrit/brash/ https://emcrit.org/pulmcrit/brash/#comments Mon, 28 Sep 2020 11:00:04 +0000 https://emcrit.org/?p=478518 BRASH syndrome refers to a vicious spiral wherein hyperkalemia and AV nodal blockers synergize to cause progressive renal failure, bradycardia, shock, and hyperkalemia.  The treatment is largely a combination of standard therapies for hyperkalemia and bradycardia.  Recognizing this syndrome as a specific entity may help us more fully understand our patients' physiology, facilitating a more […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Hemophagocytic LymphoHistiocytosis (HLH) https://emcrit.org/pulmcrit/hlh/ https://emcrit.org/pulmcrit/hlh/#comments Mon, 21 Sep 2020 20:46:04 +0000 https://emcrit.org/?p=478441 Intensivists have long been struggling with the enigma of hemophagocytic lymphohistiocytosis (HLH).  For example, this post from 2016 explores the challenge of dissecting HLH away from septic shock.  The COVID pandemic has drawn some attention to the topic, although it's not clear to what extent COVID might truly reflect HLH.  This chapter attempts to lay […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Gastrointestinal hypomotility in critical care https://emcrit.org/pulmcrit/hypomotility/ https://emcrit.org/pulmcrit/hypomotility/#comments Mon, 14 Sep 2020 14:01:41 +0000 https://emcrit.org/?p=478325 Critical illness leads to a variety of gastrointestinal motility problems (largely due to the constellation of immobility, medications, and metabolic abnormalities).  Although these topics don't generally attract much interest, maintaining adequate bowel motility is essential to avoid iatrogenic harm. The chapter on gastroparesis is located 👉 here. The chapter on ileus is located 👉 here. […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Cerebral Venous Thrombosis https://emcrit.org/pulmcrit/cvt/ https://emcrit.org/pulmcrit/cvt/#comments Mon, 07 Sep 2020 11:37:40 +0000 https://emcrit.org/?p=478196 Cerebral vein thrombosis is a neurological emergency with a frequency similar to meningitis.  We don't often think about this, but we probably should.  With early diagnosis and appropriate management, outcomes are often very good (making this one of the most treatable forms of stroke). The IBCC chapter is located 👉 here. The podcast & comments […]

EMCrit Project by Josh Farkas.

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EMCrit 281 – Why Can’t Emergency Medicine and Trauma Surgery Just Get Along? https://emcrit.org/emcrit/emergency-medicine-and-trauma-surgery-just-get-along/ https://emcrit.org/emcrit/emergency-medicine-and-trauma-surgery-just-get-along/#comments Fri, 04 Sep 2020 16:07:04 +0000 https://emcrit.org/?p=478140 Where do the fights come from?

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/emergency-medicine-and-trauma-surgery-just-get-along/feed/ 11 Where do the fights come from?
Why Can't Emergency Medicine and Trauma Surgery Just Get Along? This is a question we often ask in the USA given our unique Trauma system. It seems custom built to create conflict in the trauma bay. To explore this issue, I got to talk with Joe DuBose and Bill Teeter. This discussion originally was recorded for Joe's new podcast on Trauma Surgery, Tiger Country. Tiger Country has a bunch of episodes that are worth a listen for ED and ICU folks as well.

Joe DuBose

Trauma and Vascular Surgeon at the Shock Trauma Center. Professor of Surgery. Research leader on all things REBOA.

William Teeter

Started as a surgery resident, switched over to EM residency and then Crit Care Fellowship. Now an EM Intensivist down South.
More from DuBose

* Podcast 170 - the ER REBOA Catheter with Joe DuBose

Now on to the Podcast...
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Scott D. Weingart, MD FCCM 41:06
IBCC chapter & cast – Hypertriglyceridemic Pancreatitis https://emcrit.org/pulmcrit/hypertag/ https://emcrit.org/pulmcrit/hypertag/#comments Mon, 31 Aug 2020 10:40:32 +0000 https://emcrit.org/?p=478103 Hypertriglyceridemia is responsible for about ~10% of pancreatitis episodes seen in critical care.  The management of this entity is highly variable, due to a lack of high-quality evidence.  Approaches range from extremely aggressive (e.g. plasmapheresis) to more conservative therapy (e.g. subcutaneous insulin).  This chapter attempts to unpack the physiology and evidence underlying this diagnosis, with […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Antifungal agents https://emcrit.org/pulmcrit/antifungal/ https://emcrit.org/pulmcrit/antifungal/#comments Mon, 24 Aug 2020 13:13:57 +0000 https://emcrit.org/?p=478000 Fungal infections are becoming common among critically ill patients, as our patient population is increasingly complex and more frequently immunosuppressed.  Traditional curricula often focus on antibacterial agents rather than antifungals, leaving antifungal agents shrouded in a sense of mystery.  Antifungals actually aren't that tricky though, as there is a very limited number of them. The […]

EMCrit Project by Josh Farkas.

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EMCrit 280 – Who Should Get Angiotensin II with Rinaldo Bellomo https://emcrit.org/emcrit/when-angiotensin-ii/ https://emcrit.org/emcrit/when-angiotensin-ii/#comments Thu, 20 Aug 2020 03:41:46 +0000 https://emcrit.org/?p=477186 When should you pull the trigger on Angiotensin II for vasodilatory shock?

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/when-angiotensin-ii/feed/ 4 When should you pull the trigger on Angiotensin II for vasodilatory shock? EMCrit episode on Angiotensin II when the Athos 3 trial was fist published. Today, now that the drug has been available for a while, I wanted to hear from someone smart, with no financial conflicts of interest, on when to actually use this medication.
Rinaldo Bellomo MD PhD
Dr. Bellomo's Bio is too extensive to place here, please check out his Monash Page. Suffice it to say that he is a total badass as a clinical intensivist and a critical care researcher.

 
Renin Angiotensin Aldosterone System (RAAS)

Who Should Get Angio II

* Renin > 175 (or round up to 200)
* Septic Pts on RRT or about to need it
* Patients on pre-illness ACE-I

Rinaldo's Paper in AJRCCM

* Renin and Survival in Patients Given Angiotensin II for Catecholamine-Resistant Vasodilatory Shock

More on this Topic

* PulmCrit- Angiotensin II: five cautions & three comparisons

Now on to the Podcast...
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Scott D. Weingart, MD FCCM 26:03
IBCC chapter & cast – Nausea & antiemetics https://emcrit.org/pulmcrit/antiemetic/ https://emcrit.org/pulmcrit/antiemetic/#comments Mon, 17 Aug 2020 14:55:07 +0000 https://emcrit.org/?p=477793 Enormous attention is committed to the control of pain, with much less being directed to the control of nausea.  However, nausea and vomiting can be even more distressing than pain.  By understanding the receptor pharmacology of various antiemetics, a rational and effective approach is possible. The IBCC chapter is located here. The podcast & comments […]

EMCrit Project by Josh Farkas.

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EMCrit Wee – Is it Tamponade with Jacob Avila https://emcrit.org/emcrit/is-it-tamponade/ https://emcrit.org/emcrit/is-it-tamponade/#comments Mon, 17 Aug 2020 14:51:34 +0000 https://emcrit.org/?p=477794 Ultrasound signs of pericardial tamponade with my buddy, Jacob Avila

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/is-it-tamponade/feed/ 10 Ultrasound signs of pericardial tamponade with my buddy, Jacob Avila Core Ultrasound.
Right Atrial Collapse
greater than 1/3 of the cycle is probably the most specific

 
Right Ventricular Collapse
If the RV is collapsing when the mitral valve is open, then that is specific for tamponade

 
IVC
Lead pipe is specific, flat doesn't rule it out (if pt is volume depleted, etc.)

 
Check Out my Prior Episode with Jacob

* EMCrit 256 - RUSH Redux with Jacob Avila

Steve Alerhand has written a great review article in AJEM
Alerhand-Is it Tamponade?

 
Now on to the Wee...
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Scott D. Weingart, MD FCCM 15:03
Tox and Hound – Fellow Friday – Whence the Protons of Lactic Acidosis, Part II https://emcrit.org/toxhound/ff-lactic-acidosis-redux/ https://emcrit.org/toxhound/ff-lactic-acidosis-redux/#comments Fri, 14 Aug 2020 20:10:24 +0000 https://emcrit.org/?p=477746 Cellular Efflux of Protons and Lactate Steven C Curry, MDUniversity of Arizona College of Medicine – PhoenixBanner – University Medical Center PhoenixPhoenix, AZ@SteveCurryMD Robert A Robergs, Ph.D.School of Exercise and Nutrition Sciences, Faculty of HealthQueensland University of TechnologyBrisbane, QLD, Australia As noted in the comments in the post on the origins of protons in lactic […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast – Analgesia for the critically ill patient https://emcrit.org/pulmcrit/pain/ https://emcrit.org/pulmcrit/pain/#comments Mon, 10 Aug 2020 11:00:32 +0000 https://emcrit.org/?p=477727 It's impossible to get through a single shift in the ICU without encountering several patients experiencing pain.  Controlling pain is easy – but controlling pain while limiting collateral side-effects can be a challenge.  Anesthesiologists have pioneered the best approaches here, which often involve multimodal combinations of various medications carefully titrated to effect.  Although intensivists may […]

EMCrit Project by Josh Farkas.

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EMCrit 279 – The Decision to use Ketamine – Disruptive and Dangerous with Reub Strayer https://emcrit.org/emcrit/dangerous-and-disruptive/ https://emcrit.org/emcrit/dangerous-and-disruptive/#comments Sun, 09 Aug 2020 19:32:42 +0000 http://emcrit.org/?p=7854 I frequently see both residents and attendings inappropriately using ketamine for agitated patients. Inappropriately both by giving it when it is unecessary and giving it in poor fashion when it is indicated.

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/dangerous-and-disruptive/feed/ 26 I frequently see both residents and attendings inappropriately using ketamine for agitated patients. Inappropriately both by giving it when it is unecessary and giving it in poor fashion when it is indicated.

I frequently see both residents and attendings inappropriately using ketamine for agitated patients. Inappropriately both by giving it when it is unecessary and giving it in poor fashion when it is indicated.
Our guest today is Reub Strayer
(@emupdates). He is the author of EMUpdates.com. His research and clinical interests include checklists and standardization, airway, legislative work on the treatment of opioid dependence, and an approach to opioid misuse in the ED.

 

Reub breaks agitated patients down in to 3 groups:


1. Agitated, but Cooperative
Not a problem in the ED. Oral medications or non-pharm techniques.
2. Disruptive without Danger
Use standard anti-psychotics and sedatives, with the understanding that Haldol 5mg and Lorazepam 2 mg given IM will take a long time for full effect and even then, may not provide adequate sedation. There are better choices for this group:

* Droperidol monotherapy 5-10 mg IM or 5 mg IV
* Droperidol 5 mg + Midazolam 2mg IM or IV in the same syringe
* Olanzapine 10 mg IM (Needs Resp Monitoring)
* Olanzapine 5 mg + Midazolam 2 mg IM or IV  (Needs Resp Monitoring)
* Haldol 5 mg + Midazolam 2 mg IM or IV (will be slower than the other choices)

If using standard 5/2 (haldol and lorazepam IM), too much time for effect and impatience leads to the wrong subsequent choice, i.e. giving ketamine to this group.
3. Disruptive and Dangerous

* dangerous to staff, dangerous to self
* danger is relative to the resources of the location

Danger could be due to

* The agitation itself or
* An underlying condition that the agitation is preventing from being treated (and may be the cause of the agitation, e.g. tension pneumothorax)

Dividing Line Question: Would you consider intubation to control the situation if ketamine was not available? Reub calls this the Ketamine Litmus Test.

Ketamine takedown must be treated as Procedural Sedation (1:1 nursing observation)
Intramuscular Medication Administration

* Can go through clothes if you need to [Fleming et al.]
* Reub states maximum volume of up to 20 mls per injection

* Harrington 2005 Administer Single Site 30mL Injection Fosphenytoin - Medsurg Nursing
* Hopkins 2013 Large Volume IM Injections Review of Best Practices (Oncology) - Onc Nurse Advisor
* Ramsay 1997 IM Fosphenytoin Loading High Volumes - Epilepsy Research



Ketamine Brain Continuum
yes 23:44
IBCC chapter & cast – Inhaled Pulmonary Vasodilators https://emcrit.org/pulmcrit/pulmvaso/ https://emcrit.org/pulmcrit/pulmvaso/#comments Sat, 08 Aug 2020 13:16:25 +0000 https://emcrit.org/?p=477672 Inhaled pulmonary vasodilators are generally quite safe.  They offer a variety of physiologic benefits to patients with cardiopulmonary failure, including improved oxygenation and right ventricular function.  Unfortunately, like so many interventions in critical care, there is a dearth of large, multi-center RCTs proving patient-centered benefit.  This chapter attempts to sift through available evidence, in efforts […]

EMCrit Project by Josh Farkas.

]]> https://emcrit.org/pulmcrit/pulmvaso/feed/ 4 IBCC chapter & cast – Hyperosmolar Hyperglycemic State https://emcrit.org/pulmcrit/hhs/ https://emcrit.org/pulmcrit/hhs/#comments Mon, 03 Aug 2020 11:17:18 +0000 https://emcrit.org/?p=477605 Hyperosmolar Hyperglycemic State (previously known as “Hyperosmolar Hyperglycemic Nonketotic Syndrome” and, before that, “Hyperosmolar Hyperglycemic Nonketotic Coma”) is a bit of a slippery animal.  Despite being redefined several times, the precise definition remains elusive.  This may cause it to be over-diagnosed in anyone with severe hyperglycemia.  The treatment likewise remains a bit controversial, with different […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Guillain-Barre Syndrome https://emcrit.org/pulmcrit/gbs/ https://emcrit.org/pulmcrit/gbs/#comments Mon, 27 Jul 2020 16:27:05 +0000 https://emcrit.org/?p=477547 Guillain-Barre Syndrome is the most common cause of acute-onset neuromuscular weakness requiring ICU admission.  COVID-19 appears to be one trigger of Guillain-Barre Syndrome, so this might be even more common in the coming months.  There isn't much high-quality evidence regarding respiratory support in Guillain-Barre Syndrome, particularly when intubation is indicated.  Consequently, it's important to use […]

EMCrit Project by Josh Farkas.

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Tox and Hound – Fellow Friday – Whence the Protons of Lactic Acidosis? https://emcrit.org/toxhound/ff-lactic-acidosis/ https://emcrit.org/toxhound/ff-lactic-acidosis/#comments Fri, 24 Jul 2020 17:03:51 +0000 https://emcrit.org/?p=477277 Whence the Protons of Lactic Acidosis? The case of impaired mitochondrial electron transport Steven C Curry, MDUniversity of Arizona College of Medicine – PhoenixBanner – University Medical Center PhoenixPhoenix, AZ@SteveCurryMD Robert A Robergs, Ph.D.School of Exercise and Nutrition Sciences, Faculty of HealthQueensland University of TechnologyBrisbane, QLD, Australia **NEW** – When finished with this first part, […]

EMCrit Project by Tox & Hound.

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EMCrit 278 – Labors of Trauma – Blunt Edition (Part 1) https://emcrit.org/emcrit/emcrit-278-labors-of-trauma-blunt-edition-part-1/ https://emcrit.org/emcrit/emcrit-278-labors-of-trauma-blunt-edition-part-1/#comments Fri, 24 Jul 2020 15:19:26 +0000 https://emcrit.org/?p=477191 The complete (hopefully) menu of cognitive and operational tasks for the Trauma Team Leader for sick trauma patients.

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/emcrit-278-labors-of-trauma-blunt-edition-part-1/feed/ 14 The complete (hopefully) menu of cognitive and operational tasks for the Trauma Team Leader for sick trauma patients.
After reviewing many recordings of major trauma resuscitations, I have come to the conclusion that we are not training our learners on how to perform as a Trauma Team Leader (TTL). They are forced to extrapolate from ATLS, a course never designed for a team at a Level I trauma center. Trauma resuscitations as opposed to medical are a bounded reality. Both the time in the bay and the menu of options are limited--the complete list could be delineated and therefore available for novice TTLs. For a few weeks, I set out to do exactly that. I then sent it out to Chris Hicks (@humanfact0rz) for peer review. His feedback was so good, that I asked him to co-author this project with me. If the response to this project is positive, we will work on the penetrating edition as well.



Blue=cognitive tasks for the TTL

Red=TTL must assign to a subteam (operational)

Solid=always happens in every trauma

Dotted=May happen based on patient injuries or severity

 



* Zero Point Survey
* Team Leadership with Cliff Reid
* EMCrit #230 - Resuscitation Communication
* COMM CHECK: More On Resuscitation Communication

 



 



 



 



* Rapid Infusion Catheter

 


Revised Assessment of Bleeding and Transfusion (RABT)

* Penetrating Trauma
* Shock Index > 1.0
* Pelvic Fracture
* Positive Abdominal FAST

>=2 had sensitivity of 84% and a specificity of 77%

World J Surg 2018;42:3560

5 Sites of Bleeding

* Chest
* Intra-Peritoneal
* Retro-Peritoneal/Pelvis
* Thigh
* Street

 



* Hemostatic Resuscitation by Richard Dutton, MD
* EMCrit Podcast 30 Hemorrhagic Shock Resuscitation

 



 



 

48:06
IBCC chapter & cast – Intracranial hemorrhage https://emcrit.org/pulmcrit/ich/ https://emcrit.org/pulmcrit/ich/#respond Thu, 23 Jul 2020 11:01:00 +0000 https://emcrit.org/?p=477427 Intracranial hemorrhage is a fairly common problem, which spans the gamut from mild to life-threatening.  Most therapies haven't been shown to work, so management mostly consists of high-quality neuro-supportive care. The IBCC chapter is located here. The podcast & comments are below. Follow us on iTunes

EMCrit Project by Josh Farkas.

]]> https://emcrit.org/pulmcrit/ich/feed/ 0 IBCC chapter & cast – Catastrophic antiphospholipid syndrome (CAPS) https://emcrit.org/pulmcrit/caps/ https://emcrit.org/pulmcrit/caps/#comments Mon, 20 Jul 2020 13:55:04 +0000 https://emcrit.org/?p=477226 Catastrophic antiphospholipid syndrome (CAPS) is a truly rare cause of multi-organ failure.  It is usually not considered as a diagnostic possibility, leading it to be mis-diagnosed as septic or cardiogenic shock.  Awareness of this condition and various red flags suggesting its presence might facilitate earlier diagnosis and therapy. The IBCC chapter is located here. The […]

EMCrit Project by Josh Farkas.

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COMM CHECK: More On Resuscitation Communication https://emcrit.org/emcrit/comm-check-more-on-resuscitation-communication/ https://emcrit.org/emcrit/comm-check-more-on-resuscitation-communication/#comments Thu, 16 Jul 2020 18:25:08 +0000 https://emcrit.org/?p=477284 If the words of command are not clear and distinct, if the orders are not thoroughly understood, the general is to blame – Sun Tzu Communication During Resuscitation Communication continues to be a major issue in virtually all high-stress, time-sensitive environments.   This has been discussed a number of times on EMCrit, most recently in […]

EMCrit Project by Mike Lauria.

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IBCC chapter & cast – Fever workup in the ICU https://emcrit.org/pulmcrit/fever/ https://emcrit.org/pulmcrit/fever/#comments Mon, 13 Jul 2020 09:53:50 +0000 https://emcrit.org/?p=477213 Familiarity breeds contempt.  Fever is so common in the ICU, that we often don't put much thought into these workups.  Just culture everything, right?  Well, not really.  Excessive cultures frequently lead to false-positive results (representing colonization), which serve only to misdirect attention away from the actual problem.  Meanwhile, inadequate attention to the physical examination and […]

EMCrit Project by Josh Farkas.

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EMCrit 277 – COVID Pulmonary Physiology with Martin Tobin https://emcrit.org/emcrit/covid-pulmonary-physiology/ https://emcrit.org/emcrit/covid-pulmonary-physiology/#comments Thu, 09 Jul 2020 15:34:18 +0000 https://emcrit.org/?p=476536 COVID Pulmonary Physiology

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/covid-pulmonary-physiology/feed/ 7 COVID Pulmonary Physiology
Today on the podcast, I interview Martin Tobin on 3 papers he has recently written on COVID pulmonary physiology.
Martin Tobin

* Praise for Dr. Tobin
* Bio Page

 
Caution about Early Intubation in COVID-19
p-SILI
From 2 studies, 1 on sheep breathing with a human-equivalent Vt of 502 ml

2nd study was observational with a questionable connection to Vt--it was confounded by a number of other factors
Absence of Obtundation
 
L vs. H Subtypes
 
Physio Diversion - Looking for the Patient that needs more Inspiratory Flow

* Tobin Vent Review in NEJM



 
Basing Respiratory Management of COVID-19 on Physiological Principles
Tachypnea in Isolation is Not an Indication for Intubation
Not indicative of increased WOB
Avoiding Intubation with NIPPV
Correlation of saturation with a host of other evils, but it is possible that the saturation is merely a marker--similar to pH. Vicious cycle of shunt, low SvO2, encephalopathy, decreased resp. drive. COVID has been different, with decreased saturation without the horrible lung injury that normally accompanies it. We are also used to patient discomfort from the disease causing the hypoxemia. Retained good compliance. We have not seen the isolated hypoxemia of COVID in many situations before.

 
The Baffling Case of Silent Hypoxemia
Happy Hypoxemia vs. Silent Hypoxemia
Dr. Tobin defines silent hypoxemia as PaO2 < 60 mmHg with a PaCO2 >39 mmHg (as a PaCO2 < =39) blunts the dyspneic response to hypoxemia

Why don't they have dyspnea vs. why do they have such severe hypoxemia unaccompanied by the degree of standard badness that normally accompanies it

They do not crump

They don't develop multi-organ
Dyspnea
Purely subjective

Advanced age and diabetes may blunt dypsnea

Increase in 10 of PaCO2 causes extreme air hunger

Increase Ve when PaO2 <60, but severe hypoxemia elicits increase in ventilation only when PaCO2 > 39 mmHg [32539537]
Definition of Hypoxemia
Do we need to factor in FiO2? Dr. Tobin and I say no!

I define by pulse ox or (PaO2), doesn't matter how much O2. e.g. "He is still hypoxemic despite being placed on NRB."
When does Hypoxemia Become Dangerous?
 
Pulse Ox Inaccuracy
 
OxyHemoglobin Dissociation Curve Shifts
Fever shifts to the right, Decreased CO2 shifts left
Mechanism of Silent Hypoxemia
ACE2 is expressed in the carotid body and may be partially to blame
COVID breaks our Heuristics
Heuristic representation of how bad their lung disease actually is. Projecting expected course...

COVID first disease that unlinks it
Now on to the Podcast...
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Scott D. Weingart, MD FCCM 32:03
IBCC chapter & cast: Catheter-Associated Urinary Tract Infection (CAUTI) https://emcrit.org/pulmcrit/cauti/ https://emcrit.org/pulmcrit/cauti/#comments Thu, 09 Jul 2020 11:15:20 +0000 https://emcrit.org/?p=477116 Catheter-associated urinary tract infection (CAUTI) is supposedly one of the most common causes of nosocomial infection.  However, it's dubious to what extent it is truly a disease.  It's increasingly clear that the vast majority of cases of “CAUTI” are likely merely asymptomatic bactiuria, which has been mis-diagnosed as infection (leading to unnecessary treatment and iatrogenic […]

EMCrit Project by Josh Farkas.

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The Dantastic Mr. Tox & Howard – S03E03 – Inside Out https://emcrit.org/toxhound/s03e03-insideout/ https://emcrit.org/toxhound/s03e03-insideout/#comments Mon, 06 Jul 2020 15:21:48 +0000 https://emcrit.org/?p=477005 Ingestible electronic systems, Mario and Luigi’s new digs, and human energy harvesting with Dr. Peter Chai. We’re back! Join Dan (@drusyniak) &Howard (@heshiegreshie) as they explore the GI tract of the city, build a career of excrement, and determine which bathroom is the cleanest with Dr. Peter Chai (@PeterRchai). We hope that everyone stays safe, […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast – Sickle Cell Acute Chest Syndrome https://emcrit.org/pulmcrit/sickle-chest/ https://emcrit.org/pulmcrit/sickle-chest/#comments Mon, 06 Jul 2020 10:44:35 +0000 https://emcrit.org/?p=477027 Sickle cell disease affects 100,000 people in the United States and far more internationally.  One of the most dangerous manifestations of the disease is acute chest syndrome, which involves a vicious cycle of erythrocyte sickling and respiratory failure.  Acute chest syndrome can be a presenting feature upon hospital admission, it can arise as a complication […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Epiglottitis https://emcrit.org/pulmcrit/epiglottitis/ https://emcrit.org/pulmcrit/epiglottitis/#comments Thu, 02 Jul 2020 11:08:42 +0000 https://emcrit.org/?p=476932 The hard part about playing chicken is knowing when to flinch – Bart Mancousco, The Hunt for the Red October Epiglottitis is often a game of chicken.  The great majority of adult patients don't require intubation, so the best management for them is steroid and antibiotic (plus close observation and the ability to intubate if […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Pneumocystis Jirovicii Pneumonia https://emcrit.org/pulmcrit/pjp/ https://emcrit.org/pulmcrit/pjp/#comments Mon, 29 Jun 2020 11:42:33 +0000 https://emcrit.org/?p=476820 Pneumocystic Jirovicii Pneumonia (previously Pneumocystic Carinii Pneumonia) remains an important opportunistic infection in critical care.  Improved treatment for HIV has reduced the frequency of PJP due to AIDS, but meanwhile the development of increasingly sophisticated immunosuppressive regimens for other patient populations has increased the incidence of non-HIV PJP.  New diagnostic tests are improving our ability […]

EMCrit Project by Josh Farkas.

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EMCrit 276 – The Rapid Code Status Conversation with Kei Ouchi https://emcrit.org/emcrit/rapid-code-status-conversations/ https://emcrit.org/emcrit/rapid-code-status-conversations/#comments Thu, 25 Jun 2020 19:52:13 +0000 https://emcrit.org/?p=476339 Rapid Code Status Conversations are essential to render proper and compassionate care...

EMCrit Project by Scott Weingart.

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Today, I am joined by Kei Ouchi to disucss rapid code status discussions in Emergency Medicine and Critical Care. I came across Kei after he put up an amazing post on ALIEM with his co-author Naomi George. Conversation is the essence of palliative care--we need to be experts at them.
Kei Ouchi, MD
Kei Ouchi is an assistant professor of emergency medicine at the Brigham and Women's Hospital in Boston. He splits his time between EM and palliative care research. [@KeiO97]
Kei's and Naomi George's Guide to Rapid Code Status Conversations

More to Read

* ALIEM Post
* Prognosis after intubation study by Kei
* Long-term prognosis after MV (Kei's new study)
* Functional trajectories of older adults after critical illness
* Worse than dying
* How patients experience LTACH
* Median survival is 8 months if older adults are transferred to LTACH

 
How Kei Trained in Palliative Care Conversations
Scott, I realized I’ve never told you anything about how I trained in palliative care communications skills. I keep a record of difficult communication cases from my practice, and I regularly hire actors/role play the encounters with Susan Block (mentor) to get coaching since 2014. She is a master communicator and has been teaching this internationally for the last 35 years. I also completed the following courses and now teach Vital Talk to our trainees with palliative care folks.

* Vital Talk
* Harvard Pall Care Course

Vital Talk is adapted to EM by Corita Grudzen, who is now running a large, national study to see if this makes a difference in patient outcomes.

My ED code status conversation guide is an adaptation of the original Serious Illness Conversation Guide created by Susan Block:

 



 


Kei's Newest Article

* Kei New Article

Now on to the Podcast:
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Scott D. Weingart, MD FCCM 34:49
PulmCrit – Dexamethasone & COVID – a study in immunopathology, evidence-based medicine, and ourselves https://emcrit.org/pulmcrit/recovery/ https://emcrit.org/pulmcrit/recovery/#comments Tue, 23 Jun 2020 18:50:47 +0000 https://emcrit.org/?p=476644 Early in the COVID epidemic, it became clear that the virus often causes a cytokine storm, leading to immunopathological organ damage.   The first major study to suggest benefit from steroid in COVID was a retrospective study by Wang et al. released in early March, which found reduced mortality among COVID patients with ARDS who were […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Vocal cord dysfunction https://emcrit.org/pulmcrit/vcd/ https://emcrit.org/pulmcrit/vcd/#respond Mon, 22 Jun 2020 11:06:33 +0000 https://emcrit.org/?p=476602 Vocal cord dysfunction is a masquerader of life-threatening pathologies (most notably asthma and anatomic upper airway obstruction).  Vocal cord dysfunction itself is not dangerous, but if not properly diagnosed it may lead to considerable iatrogenic harm (e.g. multiple unnecessary intubations for “asthma”).  On the flip side, incorrect diagnosis of vocal cord dysfunction is also dangerous, […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Invasive pulmonary aspergillosis https://emcrit.org/pulmcrit/aspergillosis/ https://emcrit.org/pulmcrit/aspergillosis/#comments Mon, 15 Jun 2020 10:15:21 +0000 https://emcrit.org/?p=476479 Invasive pulmonary aspergillosis was traditionally conceptualized as a rare infection restricted to profoundly immunocompromised patients.  However, over the past decade, it's become increasingly clear that invasive aspergillosis can also occur as a nosocomial superinfection among patients who aren't immunocompromised (especially following influenza).  This opens a can of worms regarding how to sift out colonization versus […]

EMCrit Project by Josh Farkas.

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EMCrit 275 – NeuroCritical Care with Neha Dangayach https://emcrit.org/emcrit/neurocritical-care/ https://emcrit.org/emcrit/neurocritical-care/#comments Wed, 10 Jun 2020 15:54:53 +0000 https://emcrit.org/?p=476237 A Q&A format discussion of neurological emergencies

EMCrit Project by Scott Weingart.

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Today on the podcast, we discuss Neuro-Emergencies and NeuroCritical Care with Neha Dangayach. This is a wide-ranging conversation that you will truly enjoy.
Neha Dangayach
Neha is joining the EMCrit team!!!!!!

Neha S. Dangayach MD, MSCR is an Assistant Professor of Neurology and Neurosurgery. Dr. Dangayach serves as the Director of Neuroemergencies Management and Transfers (NEMAT) for the Mount Sinai Health System, Neurocritical Care Fellowship Director and Research Co-Director for the Institute for Critical Care Medicine (ICCM). She is also a Co-Director of the Mount Sinai Hospital’s busy NSICU and collaborates with a compassionate team to provide world-class patient-centered Neurocritical Care. She leads the Mount Sinai Critical Care Resilience Program (MSCCRP), a multidisciplinary program including intensivists, nursing, social workers, physical, occupation and speech therapists, chaplains, nutritionists among others. Several projects under this program seek to help patients and families cope with ICU recovery. Her research focuses on resilience, spirituality and recovery in critical care; inter-hospital transfers for neuroemergencies and social media in medicine.
Topics of Discussion with Time Stamps

Neha's Slides

* Neurocrit Care Stony Brook Grand Rounds

Neuro-Emergency Management and Transfer (NEMAT) Service


 
Tele-Stroke
Video the CT with phone

2 person job

scroll through every image of axial head ct q 2 seconds

Scroll through CTA MIPs, axial and coronal (sag is a bonus)

 
ICH
Blood Pressure
Specify how often to cycle BP cuff

Ischemic Stroke
 
Who to Intubate and Neuroprotective Intubation

* LAMW: The Neurocritical Care Intubation

 
Which Osmotic Agent for ICP

* Recently Published Guidelines

Platelet Reversal
Recent paper shows no benefit from PLTs or dDAVP in non-neurosurg bleeds [10.1097/CCM.0000000000004348]
Status Epilepticus
Choice of 2nd Line Agent
Keppra 60mg/kg (1/2 the dose in ESRD)
General Anesthetic of Choice is Midazolam
0.2 mg/kg bolus

start infusion 0.2 mg/kg/hr

titrate up every 5 minutes

max 2.9 mg/kg/hr

when getting close to 1mg/kg/hr, give ketamine 1mg/kg followed by 1 mg/kg/hr

Cirrhotics, get propofol
Now on to the Podcast...
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Scott D. Weingart, MD FCCM 1:14:22
PulmCrit Wee – Multicenter RCT evaluating ruxolitinib (a JAK inhibitor) for COVID-19 https://emcrit.org/pulmcrit/ruxolitinib/ https://emcrit.org/pulmcrit/ruxolitinib/#comments Wed, 10 Jun 2020 10:54:00 +0000 https://emcrit.org/?p=476342 Janus kinases (JAKs) are named after Janus, the Greek god of beginnings, gates, transitions, and duality.  They're named after Janus because they contain a mirror-image structural element.  However, given their role within the immune system as a multi-functional gateway for cytokine systems, the name seems apt.  The cytokine storm induced by COVID-19 has received considerable […]

EMCrit Project by Josh Farkas.

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