background on IV vitamin C We live in divided times. Paul Marik’s study on using vitamin C in sepsis was perhaps the most polarizing publication in recent memory (aside from perhaps the Mueller report). It was lauded by some, yet derided just as strongly by others. Unfortunately, the kerfuffle surrounding this study overshadowed the larger […]
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Hypocalcemia
CONTENTS Signs & symptoms EKG findings Labs Etiology Investigation of cause Treatment Intravenous calcium for refractory shock Podcast Questions & discussion Pitfalls Clinical manifestations relate to both the magnitude and acuity of hypocalcemia. symptoms Neuromuscular excitation: Anxiety, delirium, depression, coma. Paresthesias (perioral & extremities). Muscle cramping (tetany, laryngospasm), weakness, myalgias. Seizure (generalized tonic-clonic, generalized absence, […]
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: 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.
The Adventure of the Speckled Band
Blood pressure is one of the least understood and yet most intervened on metrics in modern medicine. Though we have found meager success in controlling blood pressure over the long-term (1,2) our attempts to translate these benefits to the acute setting of the emergency room have not been met with improved short-term outcomes. Traditionally acutely […]
PulmCrit- Why dialyze patients with chronic, asymptomatic hyperlithemia?
A patient with chronic asymptomatic hyperlithemia is tolerating their current lithium level well. If they have adequate renal function, their lithium level is very likely to decrease over time with hydration (and unlikely to increase). Why dialyze such a patient? It is impossible to improve a patient’s condition if the patient is already asymptomatic.
PulmCrit- .050 shades of grey in p-value cutoffs
We have a love-hate relationship with the p-value cutoff of <0.05. A p-value right below this cutoff (say, p=0.04) actually constitutes a surprisingly weak level of evidence (1). Thus, the idea of lowering the p-value cutoff has been around for a while. Unfortunately, this wouldn't really fix our problems with p-values.
Type-1 Myocardial Infarction (OMI & NOMI)
CONTENTS diagnosis Nomenclature & types of MI Diagnosis DDx of MI EKG findings in MI Anterior OMI Inferior OMI RV OMI (RVMI, including management) Posterior OMI High lateral OMI OMI in LBBB or RV-pacing OMI vs aneurysm Hyperacute T-waves & de Winter pattern Wellens patterns Subendocardial ischemia patterns Risk stratification management General supportive care PCI […]
Coagulation tests (conventional & viscoelastic)
CONTENTS Rapid Reference 🚀 Cell-based coagulation model Traditional tests of enzymatic coagulation INR prolongation with normal PTT PTT prolongation with normal INR Prolongation of both INR & PTT Thrombin Time & fibrinogen “level” (Clauss assay) Thromboelastography (TEG) Strengths and weaknesses of TEG TEG interpretation Using TEG to guide blood product transfusion Platelet dysfunction in critical […]
2015 ACLS Guidelines: What happened to VSE?
. Introduction . In 2008 and 2013, two prospective RCTs from Greece reported benefits from the combination of vasopressin, steroids, and epinephrine (VSE) for in-hospital cardiac arrest. However, other studies investigating the addition of vasopressin alone to epinephrine have been negative. Consequently, vasopressin has been removed from the AHA/ACC algorithms, with a specific recommendation […]
PulmCrit- Coagulation balance in sepsis-associated DIC
An 80-year-old man was admitted with sepsis due to liver abscess. Over the first two hospital days his platelet count decreased from 122 to 39. Prophylactic heparin was held due to concerns about bleeding risk. Additional coagulation studies showed a D-dimer of 1221 ng/ml, a fibrinogen of 672 mg/dL, and the following thromboelastograph:
“The Adventure of the Greek Interpreter Revisited”
If our affair with thrombolytics had not started off with the success it did, we may not still be trying to nostalgically relive our yesteryears of throbolytic glory. Whether it was streptokinase, alteplase or tenectoplase (TNK), thrombolytics have consistently demonstrated a mortality benefit when used in patients experiencing an ST-elevation infarction (1). If it […]
EM Nerd-The Case of the Cryptic Truth
On the morning of January 1st, 2017 a number of proud South Carolinians woke up to find themselves no longer living in their former state of residence. Without moving from the beds in which they slept, they were all magically transported into the neighboring the state of North Carolina. Due to a border dispute which […]
PulmCrit- Controlled thrombolysis of submassive PE?
Controlled thrombolysis using a slow 25-mg alteplase infusion with protocoled monitoring might offer patients the benefit of lytic therapy with an extremely low risk of severe hemorrhage.
Emergent treatment of hyponatremia or elevated ICP with bicarb ampules
. Introductory case . A young 70-kg man was transferred to the Genius GeneralICU for management of stupor. He had been diagnosed with aortic valve endocarditis due to heroin abuse two weeks earlier, but left the hospital against medical advice. Shortly after admission to Genius General, the lab called with a critical sodium value of […]
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