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.
IBCC chapter & cast: Hepatic Encephalopathy
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 […]
CC Nerd-The Case of the Needless Blockade
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 – Overdiagnosis of uncomplicated pericarditis often leads to more harm than good
On waste basket diagnoses – Pericarditis
PulmCrit: Neutrophil-Lymphocyte Ratio (NLR): Free upgrade to your WBC
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 […]
PulmCrit: Validation of test-dose strategy for beta-lactam allergies
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 247 – The Dissociated Awake Intubation with my buddy, Ketamine
All the dope on Dissociated Awake Intubation using Ketamine
IBCC chapter & cast: Rhabdomyolysis
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 – George Kovacs on Ketamine-Facilitated Intubation (KFI)
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The Case of the Magician’s Sleight
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 […]
IBCC chapter & cast: hypophosphatemia and hyperphosphatemia
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. […]
PulmCrit: Checkpoint inhibitors… for septic shock??
Background Septic shock is generally conceptualized as a state of pathological immune hyperactivity. Consequently, decades of work on immunomodulation in sepsis have focused on immunosuppressive medications (e.g. steroid, TNF-inhibitors, IL-1 inhibitors). Although most of these interventions haven’t worked, steroid offers some benefits and IL-1 receptor antagonism shows promise for a subset of patients.1 The natural […]
EMCrit 246 – Philosophical & Psychological Diversions Part I – Liberterian Free Will, Blame and Shame
A swerve from typical content
IBCC chapter & cast: The myth of contrast nephropathy
Does contrast nephropathy exist? Vigorous debate has been ongoing about this dating back to 2013.1 Hundreds of studies on the topic ultimately reveal no convincing evidence that contrast nephropathy exists. However, it’s unethical to perform a prospective RCT, so it’s impossible to ever prove this. This has left us in an evidentiary limbo – we […]
IBCC chapter & cast – Endocarditis
Endocarditis is a classic disease of emergency medicine, inpatient medicine, and critical care. The opioid epidemic has caused a surge of endocarditis diagnoses, reminding us of the myriad ways that this disease can present itself.
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