CONTENTS Epidemiology: at-risk populations Signs & symptoms Laboratory clues Evaluation of suspected adrenal crisis Clinical definition of adrenal crisis Treatment Prevention Physiology Podcast Questions & discussion Pitfalls Adrenal crisis is a bit like DKA. It can either be caused by chronic adrenal insufficiency plus a trigger, or it can be caused by acute adrenal insufficiency […]
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COMM CHECK: More On Resuscitation Communication
If the words of command are not clear and distinct, if the orders are not thoroughly understood, the general is to blame – Sun Tzu Communication During Resuscitation Communication continues to be a major issue in virtually all high-stress, time-sensitive environments. This has been discussed a number of times on EMCrit, most recently in […]
PulmCrit- Hyperdiuresis: Using hypertonic saline to facilitate diuresis
Using hypertonic saline to facilitate diuresis seems counterintuitive, paradoxical even. Volume overloaded patients have excess sodium. Why should we give them more? Let’s start by trying to understand the underlying physiology. hypochloremia may cause renal sodium retention We generally don’t pay much attention to serum chloride levels. Chloride is often viewed as a leftover, an […]
Abdominal compartment syndrome
CONTENTS Rapid Reference 🚀 Causes Epidemiology Physiological relationships between various compartments Physiology & manifestations Diagnosis Treatment Hemodynamics Decompress the abdomen Decompress the thorax Sedation & paralysis Podcast Questions & discussion Pitfalls treatment of abdominal compartment syndrome ✅ hemodynamics (more) Target MAP > (60 mm + abdominal compartment pressure). Don’t give additional fluid. Consider diuresis/dialysis, if […]
PulmCrit- The siren’s call: Double-coverage for ventilator associated PNA
Some theories are so attractive that they are nearly irresistible. No matter how many times they are disproven, these theories still seem compelling. One example is double-coverage for pseudomonas. Recently, the IDSA recommended this for ventilator-associated PNA (VAP), despite openly admitting that RCTs found it to be ineffective.
Spontaneous Bacterial Peritonitis (SBP)
CONTENTS Presenting clinical features Paracentesis Differentiating spontaneous versus secondary bacterial peritonitis Diagnosis of SBP Treatment Spontaneous bacterial empyema (SBE) Podcast Questions & discussion Pitfalls presenting signs & symptoms SBP is often subtle (for example, 13% of patients are asymptomatic).(19266595) Fever or hypothermia. Nausea/vomiting, ileus, and/or diarrhea. Abdominal pain occurs in about half of patients. However, […]
Line infection
CONTENTS Rapid Reference 🚀 Physiology Prevention Clinical features Diagnosis Management Overall strategy Empiric antibiotic selection Treatment duration Persistent bacteremia Specific situations Septic thrombophlebitis Arterial line infection Chest port infection Podcast Questions & discussion Pitfalls various mechanisms of infection: Early infections often arise from the skin: (a) These may occur during line insertion. (b) There may […]
PulmCrit- Reengineering the analgesic ladder for critically ill patients
We all want to alleviate pain and suffering. Most critically ill patients are treated with opioids for this reason. Unfortunately, opioids have numerous side-effects including delirium, constipation, vomiting, and delayed extubation. Opioid infusions may eventually lead to withdrawal, causing pain, nausea, and depression. This post explores the optimal use of systemic medications to control pain while minimizing complications.
Atypical pneumonias
CONTENTS Nonzoonotic atypical pneumonias: Legionella Mycoplasma Chlamydia pneumoniae Zoonotic atypical pneumonias: Chlamydia psittaci (psittacosis) Francisella tularensis (tularemia)* Coxiella burnetii (Q fever)* *May fail to respond to azithromycin; doxycycline will cover. Leptospirosis Questions & discussion diagnostic clues 🔍 Lack of upper respiratory features. 🔍 Extrapulmonary involvement (e.g., gastrointestinal, neurological). 🔍 Labs: Procalcitonin is usually moderately elevated. […]
The Man with the Twisted Lip
As an Emergency Medicine doctor we are trained to function in varying degrees of uncertainty. We work in a world of risk of benefits vs harms. When the benefit to harm ratio reaches a threshold for action we are taught to do so swiftly and decisively. Given this, […]
EMCrit – Critical Hyperkalemia by H. Pendell Meyers, EMCrit Intern
Critical Hyperkalemia ?s based on a recent publication
Organizing pneumonia (OP)
CONTENTS Basics Epidemiology & causes of organizing pneumonia Presentation Imaging findings Consolidation Nodule or mass Ground-glass opacities Perilobular opacities Pertinent negatives Laboratory studies Invasive diagnostics Differential diagnosis Management Questions & discussion Organizing pneumonia (OP) is a pathological form of lung response to various injuries. It involves the formation of organized plugs of fibrous tissue within […]
Hypernatremia & dehydration in the ICU
CONTENTS Rapid Reference 🚀 Why hypernatremia is important in the ICU Causes of hypernatremia Evaluation of cause Treatment Addressing specific causes Optimal rate of sodium reduction Free water replacement Is ICU admission required for elderly patients with severe hypernatremia? Podcast Questions & discussion Pitfalls routine management of hypernatremia in the ICU: (#0) If the patient […]
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 & […]
Unfractionated heparin (UFH), LMWH, fondaparinux, argatroban, and bivalirudin
CONTENTS Overview of indirect-acting anticoagulants (heparin & fondaparinux) Risk assessment Basic science – how these agents work Choice of agent Protamine for reversal of unfractionated or low molecular-weight heparin Unfractionated heparin (UFH) Dosing and monitoring of unfractionated heparin Pseudo-heparin resistance Heparin resistance Low molecular-weight heparin (LMWH) Various LMWH agents & dosing Enoxaparin dosing & monitoring: […]