February 7th 2019 marked a auspicious day in the history of the NEJM and its relationship with the pharmaceutical industry. In 2015, the NEJM shifted their significant weight in support of a strong union between industry and medicine1,2,3. With the simultaneous publication of four pharmaceutical sponsored trials, each brimming with its own unique form of […]
IBCC chapter: Buprenorphine & opioid use disorder
In critical care, we’ve been treating patients with opioid use disorder for a long time. If they’re intubated for intoxication, we extubate them and send them home. If they’re septic with endocarditis, we treat their sepsis. Unfortunately, this isn’t enough. We’re treating the complications of opioid use disorder, without addressing the underlying problem. Recently, medication-assisted […]
EMCrit 240 – Renal Compartment Syndrome & It’s all about the Venous Side and We’ve Been Fracking it up for Years
Renal Compartment Syndrome, Venous Congestion, CHF, and POCUS.
IBCC chapter: Thyroid storm
Thyroid storm is a bit of a zebra. It can mimic a variety of common conditions (e.g. sepsis, delirium, heart failure). Unfortunately, if you’re not looking for it, you probably won’t find it. Once identified, an organized multimodal treatment regimen will generally get the job done. But be careful – these patients may have varying physiology, so blindly following the same rubric for every single patient isn’t the answer.
The Case of the Incidental Bystander Continues
In October 2016 the Emergency Medicine community was faced with the publication of the now infamous PESIT trial, and the symbolic wrench its authors carelessly tossed into the already indecisive diagnostic work up of patients presenting to the Emergency Department following a syncopal event1. Published in the NEJM, Prandoni et al enrolled patients who were admitted […]
IBCC chapter & cast: thrombocytopenia & HITT
Thrombocytopenia is extremely common in critical illness. It’s generally a consequence rather than a cause of illness, predicting increased mortality. However, we must remain alert for cases where serious hematologic disease is afoot. The major concern here is the ever-looming possibility of heparin-induced thrombocytopenia and thrombosis (HITT). This chapter explores thrombocytopenia and provides an evidence-based […]
The Case of the False Dichotomy
Often in the interpretation of medical literature we are forced into false dichotomies. Compelled to choose between two hypotheses, neither of which are representative of the data presented. Such is the case with a recent trial published in Intensive Care Medicine in which Guitton et al1 examine the efficacy of apneic oxygenation during RSI in critically […]
PulmCrit- Inhaled NO for submassive PE: iNOPE or iYEP?
The use of an inhaled pulmonary vasodilator is a logical strategy for stabilization of PE patients (especially nitric oxide, which may be depleted in this situation). Previously inhaled nitric oxide has only been supported by case series.
EMCrit 239 – Vent Alarms = Code Blue
All things Vent Alarms
IBCC chapter: Antibiotics for the critically ill patient
We spend a lot of time obsessing over the finer details of critical care: which fluid is best? which vasopressor is best? will another liter of fluid help? These details are important, but for a septic patient something more important than any of these details is choosing the right antibiotic(s). In septic shock, source control and […]
IBCC chapter & cast: Undifferentiated shock
Shock is the next-door neighbor of death. Shock can present in a myriad of different forms, making early recognition challenging. However, early diagnosis is essential. Shock can be caused by a broad differential of serious illnesses. Unlike most differential diagnosis lists, every item on this differential is life-threatening. Fortunately, many causes of shock are reversible […]
PulmCrit- Vancomycin pharmacokinetics: Make vanco great again
Traditionally, vancomycin doses have been adjusted to target a specific trough level. However, it is increasingly clear that the trough level is an inadequate measurement of vancomycin exposure. Furthermore, the practice of waiting until the fourth dose to measure the trough level may expose the patient to days of suboptimal therapy.
PulmCrit- Acute infection & myocardial infarction: How afraid should we be?
Occasionally, the NEJM publishes a scary article that gets a lot of press, but doesn’t pan out to be valid. The recent example is the PESIT study, which seemed to imply that everyone admitted with syncope had PE (don’t worry- they don’t). It looks like NEJM might be at it again, with this week’s review article on the relationship between acute infection and MI.
IBCC chapter & cast: Severe influenza
Initially I wasn’t planning to write a chapter on influenza, because there is precious little evidence regarding ICU management. However, even in the absence of solid evidence, we will be called upon to treat these patients. Currently flu season is afoot, and it looks like it might be a bad one (with a predominance of […]
COMM CHECK: On Checklists
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