NIPPV with Full Face Mask for ARDS
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Recognizing and managing paradoxical reactions from benzodiazepines & propofol
. A perplexing case . A young man with a history of seizures and alcoholism presented with a generalized seizure. His seizure responded to lorazepam, but he was intubated for airway protection and was transferred to the Genius General ICU. He was also loaded with levtiracetam to prevent further seizures. . Overnight he developed agitation. Despite […]
Anticholinergic intoxication
CONTENTS Anticholinergic agents Epidemiology Clinical presentation Differential diagnosis Evaluation Management Physostigmine Treatment of agitation Other management issues Management of combined anticholinergic & sodium channel blocker toxicity Podcast Questions & discussion Pitfalls There are hundreds of substances with anticholinergic activity. Below are some of the most common and notable. agents which function predominantly as anticholinergics Atropine. […]
COVID19 – Awake Pronation – A guest write-up by David Gordon, MD
Awake Proning for COVID19
PulmCrit Wee- Proning the non-intubated patient
From the pulmonary standpoint, supine positioning may be the worst possible position. Supine positioning may promote aspiration, as gravity tends to pull oral secretions towards the larynx. Supine positioning promotes atelectasis of the posterior lung segments (which are larger and more important than the anterior segments). Among obese patients, abdominal contents compress the diaphragm when supine, further promoting atelectasis. Finally, expectoration is difficult in a supine position, as the patient must expel secretions against gravity.
High-flow nasal cannula to prevent post-extubation respiratory failure
0 Background: Post-extubation failure and noninvasive ventilation (NIV) 0 Post-extubation respiratory failure requiring re-intubation is a major setback for any critically ill patient. Current evidence mainly involves the pre-emptive use of NIV to reduce post-extubation failure, particularly in hypercapnic COPD patients. However, in practice this is difficult to implement widely. Except for the sickest COPD […]
Blastomycosis
CONTENTS Basics Epidemiology Clinical manifestations Acute pulmonary blastomycosis Radiology Chronic pulmonary blastomycosis Radiology Disseminated blastomycosis Laboratory evaluation Treatment Podcast Questions & discussion Pitfalls abbreviations used in the pulmonary section: 2 ABPA: Allergic bronchopulmonary aspergillosis 📖 AE-ILD: Acute exacerbation of ILD 📖 AEP: Acute eosinophilic pneumonia 📖 AFB: Acid Fast Bacilli AIP: Acute interstitial pneumonia (Hamman-Rich […]
PulmCrit – Is COVID-19 ARDS, pseudoARDS, L, or H? Physiology data from Boston
There has been considerable speculation in the literature regarding the physiology of intubated patients with COVID, but little actual data. A fresh study describing the physiology of intubated patients at Massachusetts General Hospital and Beth Israel offers to finally answer some questions. This is a retrospective case series involving 66 patients intubated during March 11-30. […]
Baclofen: therapy, intoxication, & withdrawal
CONTENTS Pharmacology Baclofen toxicity Diagnosis Management Baclofen withdrawal Symptoms & investigation Management: Oral baclofen withdrawal Intrathecal baclofen withdrawal Without intrathecal baclofen Podcast Questions & discussion Pitfalls pharmacokinetics Oral baclofen has a bioavailability of 70-85%, with absorption occurring within a few hours. It distributes to both the brain (where it causes sedation) and also the spinal […]
PulmCrit: Which patients admitted for pneumonia need MRSA coverage?
Let’s be honest, our decisions to cover MRSA among patients admitted to the hospital with pneumonia are haphazard. It’s not our fault. The guidelines are contradictory. For example, the MRSA guidelines by the Infectious Disease Society of America recommend coverage for everyone admitted to the ICU with pneumonia. However, pneumonia guidelines by the same society recommend coverage only for patients with specific risk factors. Fortunately, new evidence and diagnostic tools may allow us to properly treat MRSA, without drowning the entire hospital in vancomycin.
Hospital-Acquired Pneumonia (HAP)
CONTENTS Basics Epidemiology & risk factors Stepwise general approach to HAP: (1) Initial consideration for the possibility of HAP (2) Consider CT scan (3) Diagnosis & treatment of probable HAP (4) Data review over 24-72 hours (5) Ongoing management of HAP Other aspects of HAP management: Approach to treatment failure Bronchoscopy in HAP Questions & […]
PulmCrit- Ten dubious beliefs in neurocritical care
Recently Geert Meyfroidt published an article in Intensive Care Medicine describing ten false beliefs in neurocritical care shown here: It’s a great article, but I think they could have been more aggressive about challenging neurocritical care dogmas (1). In response, here is a list of ten dubious beliefs that goes farther to challenge the status quo. […]
Treating delirium tremens: Pharmacokinetic engineering with diazepam and phenobarbital
0 [PLEASE NOTE: For the most complete & updated material on alcohol withdrawal, please see the Internet Book of Critical Care Chapter on this topic here] 0 Introduction 0 Recently the New England Journal published a review article about delirium tremens which is somewhat misguided (see a scathing critique by The Poison Review). The […]
Diffuse alveolar damage (DAD) & Acute Interstitial Pneumonia (AIP)
CONTENTS Basics Causes of ARDS ARDS due to DAD ARDS without DAD Clinical presentation Radiology Bronchoscopy Investigation Diagnosis Management Questions & discussion abbreviations used in the pulmonary section: ABPA: Allergic bronchopulmonary aspergillosis 📖 AE-ILD: Acute exacerbation of ILD 📖 AEP: Acute eosinophilic pneumonia 📖 AIP: Acute interstitial pneumonia (Hamman-Rich syndrome) 📖 ANA: Antinuclear antibody 📖 […]
PulmCrit Wee: Reconceptualizing bradykinin-mediated angioedema as a universal vicious spiral
In 2015 I wrote this post on ACEi-induced angioedema. I still think it was a pretty good post (particularly for 2015), but it’s become increasingly clear recently that the post was fundamentally flawed. Let’s try to straighten this out. old model of bradykinin-mediated angioedema This is a conceptual model of how bradykinin-mediated angioedema occurs. Several […]
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