EMCrit Project https://emcrit.org Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Sat, 25 Jan 2020 12:16:48 +0000 en-US hourly 1 https://wordpress.org/?v=5.3.2 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 PulmCrit- The Rothman Index: Artificial intelligence or merely a symptom of a broken healthcare system? https://emcrit.org/pulmcrit/rothman-index/ https://emcrit.org/pulmcrit/rothman-index/#respond Sat, 25 Jan 2020 12:16:27 +0000 https://emcrit.org/?p=470621 We are constantly hunting for newer and better sources of information.  This leads to a perpetual generation of newer lab tests, different hemodynamic gizmos, and fresh decision tools.  Some of these pan out.  Most don’t. Why are these new sources of information generally disappointing?  The answer is simple:  we’re already doing pretty well.  In order […]

EMCrit Project by Josh Farkas.

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“B-Sides” in Analgesia https://emcrit.org/toxhound/b-sides/ https://emcrit.org/toxhound/b-sides/#respond Thu, 23 Jan 2020 18:58:04 +0000 https://emcrit.org/?p=470608 by Meghan Spyres Ketamine was gifted to the world as a result of investigations into its evil older brother: phencyclidine (PCP). PCP, commonly known as ‘angel dust’ (quite the misnomer, Urban Dictionary suggests the use of the more fitting ‘devil dust’. . .) was initially used as a pharmaceutical in the 1950s under trade name […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast – Toxic Alcohols https://emcrit.org/pulmcrit/alcohols/ https://emcrit.org/pulmcrit/alcohols/#respond Thu, 23 Jan 2020 13:14:53 +0000 https://emcrit.org/?p=470596 The diagnosis of toxic alcohols is a particularly controversial topic, based on recent evidence that the osmolal gap has a fairly awful sensitivity and specificity.  This chapter describes an approach to toxic alcohol diagnosis which doesn't depend on the osmolal gap.  Although this may seem radical, this strategy has been previously recommended by other authors […]

EMCrit Project by Josh Farkas.

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PulmCrit – An alternative view of the PEPTIC trial https://emcrit.org/pulmcrit/peptic/ https://emcrit.org/pulmcrit/peptic/#comments Wed, 22 Jan 2020 12:39:42 +0000 https://emcrit.org/?p=470539 The PEPTIC multi-center RCT compared histamine-2 receptor blockers (H2RBs) versus proton pump inhibitors (PPIs) for stress ulcer prophylaxis among ventilated ICU patients.​1​  It’s a landmark trial of unprecedented size and statistical power.  PEPTIC was presented at the Critical Care Reviews meeting in Ireland and live-cast around the world (available here).  This presentation and the editorials […]

EMCrit Project by Josh Farkas.

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EM Nerd: The Case of the Sour Remedy Continues https://emcrit.org/emnerd/em-nerd-the-case-of-the-sour-remedy-continues/ https://emcrit.org/emnerd/em-nerd-the-case-of-the-sour-remedy-continues/#comments Mon, 20 Jan 2020 19:14:48 +0000 https://emcrit.org/?p=470507 The use of IV vitamin C as a therapeutic agent in sepsis has caught the hearts and minds of emergency medicine and critical care clinicians. Since the publication of a small single center before and after study by Marik et al in 2017 (1), we have spent countless hours screaming into the void that is […]

EMCrit Project by Rory Spiegel.

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PulmCrit- Metabolic Resuscitation: Was the answer inside us all along? https://emcrit.org/pulmcrit/vitamins/ https://emcrit.org/pulmcrit/vitamins/#comments Fri, 17 Jan 2020 12:33:15 +0000 https://emcrit.org/?p=470415 Now that VITAMINS is published, it’s worth trying to look at the big picture of sepsis treatment with hydrocortisone, ascorbate, and thiamine (HAT).  Marik et al. 2017:  The beginning HAT therapy began with a single-center, before/after study.​1​ There was a stark mortality reduction following the routine adoption of HAT therapy in septic shock (figure below, […]

EMCrit Project by Josh Farkas.

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Tox & Hound – MALA-ficence https://emcrit.org/toxhound/mala/ https://emcrit.org/toxhound/mala/#respond Wed, 15 Jan 2020 14:14:07 +0000 https://emcrit.org/?p=470391 Predicting Outcome in Metformin Lactic Acidosis by Diane Calello A 56-year-old male with diabetes and hepatitis comes in after an intentional overdose of his own metformin. On evaluation, he is awake and alert but mildly tachycardic. Lab evaluation demonstrates elevated lactate at 4 mmol/L and a pH of 7.3. Will he die? Metformin is one […]

EMCrit Project by Tox & Hound.

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EMCrit Podcast 263 – The Venous Side – Part 1 – VEXUS Score with Phillipe Rola https://emcrit.org/emcrit/vexus-score/ https://emcrit.org/emcrit/vexus-score/#comments Tue, 14 Jan 2020 16:01:31 +0000 https://emcrit.org/?p=470292 The VEXUS Score - A way to quantitate how badly you overloaded your patient...

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/vexus-score/feed/ 2 The VEXUS Score - A way to quantitate how badly you overloaded your patient...
Today, we discuss the VEXUS Score. One of the big philosophical mistakes of early EMCrit was my approach to fluids in sepsis. It is no excuse that I was in good company--as in most of the intensivists in the US. I've come to my senses in the past 8 years or so and now I am actively fighting to avoid the drowning of our patients. One of the stalwarts in that fight is my buddy Phillipe Rola. He is an intensivist in Montreal, EMCrit team member, and creator of the Thinking Critical Care Blog.

He, along with Rory Spiegel and Korbin Haycock, has created the VEXUS score to evaluate your patient for fluid overload.
VEXUS Score

Hepatic Vein
Look at the IVC in the sub-xiphoid

Phased Array Probe may be easiest, but Curvilinear works as well

S wave should be larger than D wave

TR may be a confounder

S just after QRS if you have ECG leads
Portal Vein
Mid-Ax Line on Right Side with probe longitiduinal or R Costal Margin

Use curvilinear

Flow should move towards probe (red)

Normal is continuous flow

If it becomes pulsatile, there is backpressure

If it drops below baseline that is bad

PF <=0.5 (same thing as resistive index)

may be abnormal in pts with low BMI
Renal Artery
Curvilinear with Abd preset

Use color doppler to find vessels

Pick a vessel and look at the PW wave

RRI

0.55-0.7 is normal

Approaches 1 when there is an absence of diastolic flow

IRVF

Look for vein in parenchyma

 

from JACC HF 2016;4(8):683

 
Katie Wiskar Tutorial


Katie's Slide of Confounding Factors
Venous Excess Chapter from Phillipe's Book
venous-congestion-chapter
More from Phillipe on this Topic

* EMCrit Podcast 240- Renal Compartment Syndrome It's all about the Venous Side and We've Been Fracking it up for Years
* Posts on Thinking CC

Literature

* Tang Editorial JACCHF 2016

Resus Crisis Manual

Now on to the Podcast...
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Scott D. Weingart, MD FCCM clean 24:30
IBCC chapter & cast – Central line infection https://emcrit.org/pulmcrit/line/ https://emcrit.org/pulmcrit/line/#comments Tue, 14 Jan 2020 13:46:08 +0000 https://emcrit.org/?p=470346 Prevention and treatment of central line infections is a core competency in critical care.  Prevention is the true key here.  Achieving zero central line infections is an unreachable goal, but with diligence the rate can be pushed close to zero. The IBCC chapter is located here. The podcast & comments are below. Follow us on […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Deresuscitation (Dominating the Diuresis) https://emcrit.org/pulmcrit/diurese/ https://emcrit.org/pulmcrit/diurese/#comments Thu, 09 Jan 2020 12:19:07 +0000 https://emcrit.org/?p=470256 Large-volume diuresis is a topic that isn't discussed much in critical care curricula or textbooks.  Nonetheless, this is a daily reality for intensivists, especially those living in the United States (where patients continue to be empirically treated with 30 cc/kg fluid as initial fluid bolus, for a broad variety of complaints).  This chapter attempts to […]

EMCrit Project by Josh Farkas.

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PulmCrit- Sepsis special edition & CBC to diagnose septic shock https://emcrit.org/pulmcrit/cbc-sepsis/ https://emcrit.org/pulmcrit/cbc-sepsis/#comments Mon, 06 Jan 2020 12:08:19 +0000 https://emcrit.org/?p=470197 The Journal of Thoracic Diseases is about to release a special edition on sepsis, edited by Paul Marik (open access).  It’s deliciously rebellious – just look at the table of contents 👇 My article on using the complete blood count to diagnose sepsis is already available, so I’ll summarize it here (yes, I know, you […]

EMCrit Project by Josh Farkas.

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EMCrit Guest Post – Bougie Lessons from the Literature and Experience by George Kovacs https://emcrit.org/emcrit/bougie-lessons-from-the-literature/ https://emcrit.org/emcrit/bougie-lessons-from-the-literature/#comments Fri, 03 Jan 2020 23:54:27 +0000 https://emcrit.org/?p=470145 George Kovacs' take on Bougie Use

EMCrit Project by Guest Author.

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IBCC chapter & cast – Myxedema coma (decompensated hypothyroidism) https://emcrit.org/pulmcrit/myxedema/ https://emcrit.org/pulmcrit/myxedema/#comments Thu, 02 Jan 2020 12:23:47 +0000 https://emcrit.org/?p=470114 Myxedema coma is a misleading misnomer.  Most patients don't have non-pitting edema (myxedema), nor are they frankly comatose.  The best way to think about this disease is simply decompensated hypothyroidism.  Patients with under-treated or untreated hypothyroidism have no metabolic reserve.  Stressors may easily push them into multi-organ failure. Myxedema coma is easily missed, because it […]

EMCrit Project by Josh Farkas.

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Tox and Hound – Happy New Year! https://emcrit.org/toxhound/happynewyear2020/ https://emcrit.org/toxhound/happynewyear2020/#respond Tue, 31 Dec 2019 21:08:55 +0000 https://emcrit.org/?p=470065 We here at the hive mind of the Tox and the Hound just want to thank you, dear readers, for joining us on this incredible journey. We’ve had an exciting year, where we’ve talked about a wide range of topics and ideas. We discussed . . . Post mortem drug redistribution Buprenorphine in the ER […]

EMCrit Project by Tox & Hound.

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Tox and Hound – All Drugs Go to Heaven https://emcrit.org/toxhound/drugheaven/ https://emcrit.org/toxhound/drugheaven/#comments Mon, 30 Dec 2019 20:20:40 +0000 https://emcrit.org/?p=469999 by Andrew Stolbach “Who cares about that?” This is what my supportive wife (who also happens to be a doctor) said when I told her I wanted to write about postmortem drug testing. I can understand where she is coming from. Before writing something, it is valid to ask if this is something that my […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast – Noninvasive respiratory support (BiPAP & HFNC) https://emcrit.org/pulmcrit/support/ https://emcrit.org/pulmcrit/support/#respond Sat, 28 Dec 2019 10:56:42 +0000 https://emcrit.org/?p=469944 Noninvasive respiratory support is among the greatest recent advances in critical care.  When used properly, these techniques may facilitate avoidance of intubation, reduced length of stay, and better outcomes.  Unfortunately, our knowledge of exactly how to use these devices remains woefully incomplete.  In particular, there are rather few RCTs directly comparing BiPAP versus HFNC. In […]

EMCrit Project by Josh Farkas.

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EMCrit 262 – Midlines – Part 1 https://emcrit.org/emcrit/midlines-1/ https://emcrit.org/emcrit/midlines-1/#comments Fri, 27 Dec 2019 23:06:30 +0000 https://emcrit.org/?p=469921 Midlines can change your vascular access practice

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/midlines-1/feed/ 33 Midlines can change your vascular access practice Our Article

* Utility of Midlines in Ann Emerg Med 2020

What the Heck is a Midline?
a 8-25 cm catheter that is placed in the arm and doesn't extend past the shoulder
Why Ultrasound-Guided IVs Suck?

* They aren't long enough [30021833]
* Nearly 1/2 of them are dislodged in 24 hrs [Ann Emerg Med 1999;34(6):711]
* Another study demonstrating they do not last [AJEM 2010;28:1]
* Vessel Depth and Catheter Depth are the key to longevity [AJEM 2011 Fields et al.]
* Need 2.75 cm in the vessel for good reliability [https://doi.org/10.1016/j.annemergmed.2019.11.013]

Which Midlines Do We Use?
10 cm Midline
Bard Powerglide ST


20 cm Midline
Medcomp 20 cm 5F CT Midline



 

 

I take no money from any of these folks
Video of the Dual-Lumen Midline Placement
Start at 7:10
The Hospitalist & the Resuscitationist 2020
Phillipe Rola and a panoply of rogues will be discussing amazing things in beautiful Montreal

May 20-22, 2020

* See the Poster
* Check out the Conference

Send Me ?s below or on Twitter
Now on to the Podcast...]]>
Scott D. Weingart, MD FCCM clean 24:30
The Dantastic Mr. Tox & Howard – S03E02 – All I Want for Christmas is Two New Base Pairs https://emcrit.org/toxhound/s03e02-crispr/ https://emcrit.org/toxhound/s03e02-crispr/#comments Wed, 25 Dec 2019 17:48:46 +0000 https://emcrit.org/?p=469877 Genetic terrorism and CRSPR with Dr. Jillian Theobald Join Dan (@drusyniak) &Howard (@heshiegreshie) as they explore the world of gene editing with Dr. Jillian Theobald (@JillianTheobald). Dive deep into CRISPR and how it is revolutionizing the way we view the genome and what can be done with it, both good and bad. From Bristle blocks […]

EMCrit Project by Tox & Hound.

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EM Nerd-The Case of the Adjacent Contradictions https://emcrit.org/emnerd/em-nerd-the-case-of-the-adjacent-contradictions/ https://emcrit.org/emnerd/em-nerd-the-case-of-the-adjacent-contradictions/#comments Mon, 23 Dec 2019 20:03:01 +0000 https://emcrit.org/?p=469856 There has been a long-standing debate in the fields of emergency medicine and critical care regarding the ideal paralytic agent to use during RSI, rocuronium or succinylcholine. This dispute, has even developed slogans such as Roc Rocks, Sux Sucks as one side attempts to definitively proclaim its superiority through witty aspersions. But up until now […]

EMCrit Project by Rory Spiegel.

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Tox and Hound – We Have A MOUD* Disorder https://emcrit.org/toxhound/mouddisorder/ https://emcrit.org/toxhound/mouddisorder/#comments Mon, 23 Dec 2019 17:17:39 +0000 https://emcrit.org/?p=469817 by Howard Greller A 37-year-old man with a history of asthma and hypothyroidism presents to your emergency department complaining that he hasn’t been feeling well for a few days. He reports having chills, nausea without vomiting, some loose stool, diffuse body aches, some rhinorrhea, and feeling ill at ease. In your detailed history, it is […]

EMCrit Project by Tox & Hound.

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PulmCrit- Nebulized nitroglycerin: The stealth pulmonary vasodilator hiding under your nose? https://emcrit.org/pulmcrit/ntg/ https://emcrit.org/pulmcrit/ntg/#comments Sat, 21 Dec 2019 10:55:50 +0000 https://emcrit.org/?p=469764 Recently Sara Crager released a video on EM-RAP recommending inhaled milrinone or nitroglycerin as an emergency therapy for massive pulmonary embolism (in case you don’t have access to EM-RAP, an audio clip from the video is below).  This is the first that I’ve heard of using inhaled nitroglycerin.  It seems like a pretty neat idea, […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Acute promyelocytic leukemia https://emcrit.org/pulmcrit/apl/ https://emcrit.org/pulmcrit/apl/#respond Thu, 19 Dec 2019 14:03:09 +0000 https://emcrit.org/?p=469727 Acute promyelocytic leukemia (APL) is a unique leukemia, with particular importance to resuscitationists.  Unlike most leukemias, the highest rate of mortality occurs at the time of diagnosis (a phenomenon known as “early deaths”).  If patients are able to survive the initial phase of illness, the cure rate is extremely high (>90%).  Aggressive support in the […]

EMCrit Project by Josh Farkas.

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Pulmcrit Wee- Rare catastrophic complications, heparin, and succinylcholine: Sometimes excellent is the enemy of perfect. https://emcrit.org/pulmcrit/rare-catastrophic-complications/ https://emcrit.org/pulmcrit/rare-catastrophic-complications/#comments Wed, 18 Dec 2019 14:53:42 +0000 https://emcrit.org/?p=469700 A multi-center RCT was released yesterday comparing rocuronium versus succinylcholine.  It’s a thoroughly uninformative study, so at first I wasn’t planning to write about it.  But then I realized that the study, in its very myopia, is a good illustration of our problem with rare catastrophic complications. warmup:  heparin infusions and rare catastrophic complications A […]

EMCrit Project by Josh Farkas.

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PulmCrit- Furosemide failure: should we add metolazone, IV chlorothiazide, or… tolvaptan?!? (3T trial) https://emcrit.org/pulmcrit/3t-trial/ https://emcrit.org/pulmcrit/3t-trial/#comments Mon, 16 Dec 2019 12:24:23 +0000 https://emcrit.org/?p=469630 Diuretics are a bit like vasopressors.  We use them all the time, so we feel that we know them pretty well.  However, the amount of RCT-level evidence on them is shockingly low.  So, whenever a RCT on diuretics shows up, it’s worth careful examination. the 3T trial:  basics This is a single-center, double-blind trial involving […]

EMCrit Project by Josh Farkas.

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EMCrit 261 – Thrombolysis during Cardiac Arrest https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/ https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/#comments Thu, 12 Dec 2019 18:50:40 +0000 https://emcrit.org/?p=469590 Who should we thrombolyse during cardiac arrest?

EMCrit Project by Scott Weingart.

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Do you administer thrombolytics during cardiac arrest? Or maybe you don't believe in thrombolytics, but are totally down with fibrinolytics during arrest. Who do you administer them to and which one do you use? I give you my own circuitous ramblings on the topic in this episode.
Who Should Get Lysed?



SR/MA

* Wang et al.

RCT Mentioned

* TROICA (19092151)

Studies not Included in that SR/MA




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






What Lytic?



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





How Long Should You Keep Going?








* 30-60 minutes after lytic administration

===Ad from Friends===
EZDrips APP
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Thanks again!Fred and JF

Update
Evidence on the lack of utility of the RV during arrest to dx PE
Now on to the Podcast...


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

EMCrit Project by Josh Farkas.

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

EMCrit Project by Tox & Hound.

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

EMCrit Project by Josh Farkas.

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

EMCrit Project by Josh Farkas.

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

EMCrit Project by Tox & Hound.

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

EMCrit Project by Scott Weingart.

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NEJM recently published an interesting review article on upper airway obstruction. This podcast was spurred by a rantorial on twitter by Farkas regarding the article:

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

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

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

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

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

Updates:
Best Practices for Emerg Surg Airway (Laryng Invest Otolaryng 2019;4:602)
Now on to the Podcast...
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Scott D. Weingart, MD FCCM clean 21:23
PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad? https://emcrit.org/pulmcrit/esett/ https://emcrit.org/pulmcrit/esett/#comments Sat, 30 Nov 2019 13:20:26 +0000 https://emcrit.org/?p=469282 The management of generalized convulsive status epilepticus remains in perpetual status controversius.  There is consensus that the front-line agent should be a benzodiazepine, but little agreement beyond that.  The much-awaited ESETT trial is a multi-center RCT comparing three anti-epileptic agents for ongoing status epilepticus (levetiracetam, fosphenytoin, and valproate).  This trial will be the highest-quality evidence […]

EMCrit Project by Josh Farkas.

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

EMCrit Project by Josh Farkas.

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

EMCrit Project by Josh Farkas.

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

EMCrit Project by Tox & Hound.

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

EMCrit Project by Josh Farkas.

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

EMCrit Project by Josh Farkas.

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

EMCrit Project by Scott Weingart.

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

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

Acting Assistant Professor of Emergency Medicine, UW Medicine

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

@JenelleBadulak



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

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



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

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

Pure Left ventricular vs. Bi-ventricular/RV Failure


Decide on MCS Strategy

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

Additional Resources





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

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

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

EMCrit Project by Rory Spiegel.

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