CONTENTS core considerations for every patient Bedside hemodynamic assessment Why is this patient presenting with heart failure? [Rx 1] Fix the lungs [Rx 2] Optimize the MAP/afterload [Rx 3] Optimize volume status [Rx 4] Consider inotrope for HFrEF (including digoxin) [Rx 5] Treat underlying etiology [Rx 6] Mechanical circulatory support [Rx 7] Things to avoid […]
Search Results for: septic shock
EM Nerd-The Case of the Conspicuous Conclusion
The process of rapid sequence induction (RSI) often forces the clinician to choose between two conflicting priorities. Torn between maintaining a safe level of oxygen, rendering the patient apneic, and limiting the amount of positive pressure ventilatory support given prior to obtaining a secure airway in the hopes of minimizing the risk of aspiration. Traditionally […]
Post-cardiac arrest management
CONTENTS Rapid Reference 🚀 Cause & investigation Subsequent management: Targeted temperature management (TTM) Shivering management Cardiovascular interventions Pulmonary optimization ID: Aspiration pneumonia & antibiotics Endocrine: steroid Neurologic issues Podcast Questions & discussion Pitfalls investigations ✅ labs Fingerstick glucose. Basic labs (electrolytes including Ca/Mg/Phos, CBC, INR, PTT). Lactate. Troponin. Blood cultures if concern for sepsis. Pregnancy […]
Right Ventricular failure
CONTENTS Rapid Reference: Approach to RV failure 🚀 Preamble: Don’t forget the right ventricle! Pathophysiology of RV failure RV death spiral RV myocardial perfusion Falling off the Starling curve Occult systemic hypoperfusion Diagnosis of RV failure Defining RV failure Physical exam findings Lab findings Radiology EKG Echocardiography Causes of right ventricular failure Chronic pulmonary hypertension […]
Abdominal compartment syndrome
CONTENTS Rapid Reference 🚀 Causes Epidemiology Physiological relationships between various compartments Physiology & manifestations Diagnosis Treatment Hemodynamics Decompress the abdomen Decompress the thorax Sedation & paralysis Podcast Questions & discussion Pitfalls treatment of abdominal compartment syndrome ✅ hemodynamics (more) Target MAP > (60 mm + abdominal compartment pressure). Don’t give additional fluid. Consider diuresis/dialysis, if […]
EMCrit 162 – Assessing Fluid Responsiveness
yep, more on fluid responsiveness
PulmCrit- Power, the forgotten error, and inconclusive trials
The new HYPRESS trial tests whether steroid could prevent deterioration from sepsis into septic shock. The study found no significant benefit from steroid, but I thought it was underpowered. However, an accompanying editorial in JAMA didn’t even mention power. This raises some questions: How can we measure type-2 error? How should it be reported? What is an acceptable level of type-2 error?
Top 10 reasons to stop cooling to 33C
Introduction 0 Following the Nielsen study, many hospitals developed two protocols for temperature management after cardiac arrest (33C or 36C). For example, the 36C protocol could be used for patients with contraindications to hypothermia (33C). With ongoing evidence emerging about hypothermia, many hospitals are abandoning their 33C protocols and using 36C for all post-arrest patients. […]
Approach to new fever or rigors in the ICU patient
CONTENTS Definition & classification of fever Common causes of fever Evaluation Management Specific fever types Drug fever Neurogenic fever Podcast Questions & discussion Pitfalls definition of a fever Fever is a bedrock concept in medicine, yet its precise definition remains a bit elusive. The Infectious Disease Society of America defined fever in the ICU as […]
CC Nerd-The Case of the Neutral Documents
A brief editorial aside: Both Josh and Scott have commented on the BICAR-ICU Trial in previous posts, each presenting well thought out erudite analyses. I recommend reading/listening to them. EMCrit: Acid Base Episode 7 PulmCrit: pH-guided fluid resuscitation & BICAR-ICU The overwhelming need for euboxia has inspired a multitude of therapeutic endeavors, including the use of […]
PulmCrit- BRASH syndrome: Bradycardia, Renal failure, Av blocker, Shock, Hyperkalemia
This is one of my favorite diagnoses. When first encountered, it may seem bewildering and difficult to treat (1). Indeed, standard ACLS algorithms often fail with these patients. However, once understood, this disorder is easily treated and patients typically improve rapidly.
PulmCrit- Get SMART: Nine reasons to quit using normal saline for resuscitation
Saline vs. balanced solutions has been a topic of ongoing debate. Two fresh studies will illuminate this: the SMART and SALT-ED trials. This post summarizes current knowledge, beginning with physiology and working our way to fresh trials. Reason #1. There is no physiologic rationale for using “normal” saline (NS). Saline is a hypertonic, acidotic fluid […]
Decompensated Hypothyroidism (“Myxedema Coma”)
CONTENTS Rapid Reference 🚀 Diagnosis Epidemiology (including triggers) Recognition of the clinical syndrome Catalog of potential findings Investigations Definition & differential Treatment Treatment of cause Supportive care Hormonal manipulations Stress dose steroid IV levothyroxine (T4) Liothyronine (T3) Followup Podcast Questions & discussion Pitfalls basic workup should include: Endocrine evaluation: TSH & free T4. Random serum […]
Ventilator Associated Pneumonia (VAP)
CONTENTS Rapid Reference 🚀 Preamble: The riddle of VAP Stepwise approach to VAP Step #1 – Does the patient have probable VAP? Step #2 – Pulling the trigger on antibiotics & cultures Step #3 – Management of suspected VAP #3a) Cultures & repeat imaging #3b) Antibiotics for probable VAP Step #4 – Data review & […]
PulmCrit- Chasing mortality endpoints is a fool’s errand
“There is no mortality benefit for that.” How many times have you heard that? The implication is usually the same: that intervention is a waste of time. A smart, evidence-based clinician wouldn’t bother with it. But, what does it actually mean if there is no proven mortality benefit?
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