A 55-year-old woman was admitted with toxic shock syndrome. Her norepinephrine requirement was labile, fluctuating between 15 mcg/min and 30 mcg/min. Bedside echocardiogram showed a dilated inferior vena cava without respiratory variability, and a normal ejection fraction. On examination her extremities were cool and her urine output was marginal.
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Atrial Fibrillation (AF) & Flutter complicating critical illness
CONTENTS Introduction Diagnosis of AF Investigation of the cause of AF Management – Overall approach Emergent cardioversion Is immediate cardioversion indicated? How to perform DC cardioversion (1) Universal AF stabilization package (2) Rate vs. rhythm control decision Rhythm control in critical illness Rate control (3) Anticoagulation Atrial flutter Pharmacopeia for AF in the ICU: Amiodarone […]
Immune-related adverse events from checkpoint inhibitors
CONTENTS Rapid reference 🚀 Introduction to checkpoint inhibitors Core principles of immunotherapy-related adverse events Immune-related adverse events in the ICU Specific organ-system involvement Cardiac Pneumonitis Colitis Hepatitis Nephritis Endocrine Neurologic Hematologic Dermatologic Podcast Questions & discussion Pitfalls basic tests to consider in critically ill patient s/p checkpoint inhibitor (more) Labs: CBC with differential, electrolytes. Coagulation […]
PulmCrit- Nonsedation in ventilated patients: Two dueling RCTs
A new study in NEJM compared nonsedation with light sedation in ventilated ICU patients. This is a follow-up study, aimed at clarifying the results of a prior trial at the same center. To best understand the current study, we need to start with the first trial… Strom et al. 2010: A protocol of no sedation […]
PulmCrit- Sepsis Research Rant: More fake news, less real news
The following rant focuses on sepsis research, but these principles are universal. I apologize for the agitated nature of this post, but I just can’t hold it in any longer. If I read one more correlational study which tries to imply causation, I might just explode. In order to prevent burnout, I’m going to journal these thoughts instead. So, hang on to your hats, because things are going to get a bit heated.
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 […]
Acute colonic pseudo-obstruction (Oglivie’s syndrome)
CONTENTS Basics Clinical presentation Differential diagnosis Evaluation Causes Approach & management Podcast Questions & discussion Pitfalls definition Acute colonic pseudo-obstruction refers to a paralytic ileus of the colon which causes severe colonic dilation. In some cases the small bowel may also be involved. This is not due to anatomic obstruction, but rather due to hypomotility. […]
PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?
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 […]
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.
EM Nerd-A Case of Confounding Factors
So much of our critique of the medical literature is focused on the quantification of random error. Attempting to differentiate a true divergence of sample populations from random chance. Typically, we assess this probability via the p-value. This number represents the likelihood that the results observed, or a more extreme version, would occur if no […]
Dear NEJM: We both know that conflicts of interest matter.
0 Introduction 0 Recently the New England Journal of Medicine launched a media campaign challenging the negative perception of industry conflicts of interests (COI). This was surprising, because it is the opposite of what editors of the NEJM have previously reported (see above books by former NEJM editors, published in 2004 and 2005). Big pharma […]
A Secondary Examination of The Adventure of the Cardboard Box
In November of 1995 stroke care as we know it drastically and permanently changed. With the publication of NINDS-2 the NEJM ushered in the interventional era of acute ischemic stroke (1). No longer were we powerless in our management of these patients. Finally we could offer them more than an aspirin to chew on, a […]
PulmCrit – A history of hypothermia for cardiac arrest, 2002-2021 (RIP)
Let’s start by considering what our pretest probability should be regarding whether hypothermia is beneficial after cardiac arrest. Every enzyme in our body has been evolutionarily designed to function at our normal body temperature. Therefore, hypothermia will affect every chemical pathway. As such, hypothermia is an incredibly blunt tool. It’s hard to think of any […]
PulmCrit: We should engineer a new crystalloid
Considering the importance of crystalloid in critical care, one might expect crystalloid composition to be meticulously engineered and updated. However, our crystalloid choices remain archaic. Normal saline and Lactated Ringers (LR) were developed in the 1800s, whereas Plasmalyte and Normosol emerged in the 1970s.
Neuro-Oncology Emergencies
NEURO-ONCOLOGY Approach to nonspecific presentations Direct effect of tumor mass Focal mass effect with edema Primary CNS lymphoma (PCNSL) Pituitary apoplexy Spinal cord compression Leptomeningeal carcinomatosis Vascular Acute Ischemic Stroke Intracerebral Hemorrhage Cerebral Venous Thrombosis Intravascular large B-cell lymphoma Seizure Paraneoplastic syndromes Iatrogenic Radiation therapy Chemotherapy PRES due to chemotherapy Checkpoint inhibitors: Immune-Related Adverse Events […]
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