Introduction Traditional coagulation studies (especially the INR) fail miserably in cirrhosis. Thromboelastography (TEG) is a superior approach for understanding the global balance of pro-coagulants versus anti-coagulants in these patients. This isn’t anything particularly new – for example, it was explored in this post from 2015 (if you’re not familiar with this concept already, it’s explained […]
Search Results for: acid base
Pulmonary disorders of calcification & metastatic bone formation
CONTENTS Pulmonary alveolar microlithiasis (PAM) Metastatic pulmonary calcification (MPC) Differential diagnosis of pulmonary calcification & ossification Questions & discussion abbreviations used in the pulmonary section: 8 ABPA: Allergic bronchopulmonary aspergillosis 📖 AE-ILD: Acute exacerbation of ILD 📖 AEP: Acute eosinophilic pneumonia 📖 AFB: Acid-fast bacilli AIP: Acute interstitial pneumonia (Hamman-Rich syndrome) 📖 ANA: Antinuclear antibody […]
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, […]
Adrenal crisis
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 […]
Pulmonary alveolar proteinosis (PAP)
CONTENTS Basics Epidemiology Clinical presentation Radiology Bronchoscopy Laboratory studies Diagnosis Treatment Questions & discussion abbreviations used in the pulmonary section: 7 ABPA: Allergic bronchopulmonary aspergillosis 📖 AE-ILD: Acute exacerbation of ILD 📖 AEP: Acute eosinophilic pneumonia 📖 AFB: Acid fast bacilli AIP: Acute interstitial pneumonia (Hamman-Rich syndrome) 📖 ANA: Antinuclear antibody 📖 ANCA: Antineutrophil cytoplasmic […]
Nontuberculous mycobacteria (NTM)
CONTENTS Basics Epidemiology Clinical manifestations Fibrocavitary disease Nodular bronchiectatic disease (Lady Windermere syndrome) NTM in cystic fibrosis NTM in non-CF (cystic fibrosis) bronchiectasis Disseminated Mycobacterium avium complex (MAC) Hypersensitivity pneumonitis due to NTM Diagnosis Significance of positive culture Relative pathogenicity of different species Diagnostic criteria Decision to treat Treatment Treatment overview Antibiotic regimens for various […]
PulmCrit- SUP-ICU: Is pantoprazole the elixir of life? Should it be?
SUP-ICU is a massive, modern RCT of stress ulcer prophylaxis (SUP) in the ICU. With 3298 patients, it is larger than many meta-analyses of SUP. Its primary mortality endpoint is deeply flawed. However, the study still provides a wealth of information about SUP in the ICU.
PulmCrit- Six myths promoted by the new surviving sepsis guidelines
Early Goal-Directed Therapy: A house collapsing in slow motion The original foundation of the Surviving Sepsis Campaign was the Rivers trial on early goal-directed therapy. This is basically the NINDS trial of the critical care world: a study with ~300 patients showing implausibly positive results, published in NEJM, and rapidly brainwashing an entire discipline. The […]
PulmCrit- CITRIS-ALI: Can a secondary endpoint stage a coup d’état?
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 […]
Local Anesthetic Systemic Toxicity (LAST)
CONTENTS Epidemiology Presentation Differential diagnosis Treatment Podcast Questions & discussion Pitfalls patient-dependent risk factors Hepatic dysfunction: Most anesthetics are hepatically cleared. Clearance rate is most relevant if the agent is slowly absorbed, administered in multiple doses, or provided as a continuous infusion. Cardiac dysfunction: Reduced cardiac reserve function may render LAST more dangerous (e.g., patients […]
Tuberculosis
CONTENTS Epidemiology & risk factors Clinicoradiologic forms Natural history of tuberculosis Primary pulmonary TB Tuberculous pleural effusion ➡️ Chronic tuberculous empyema ➡️ Healed tuberculosis (Ghon complex) Postprimary TB Miliary TB Acute miliary TB Subacute/chronic miliary TB Tracheobronchial involvement Laryngeal TB Diagnosis of active pulmonary TB: overview Red flags to consider the diagnosis of TB Initial […]
PulmCrit- Epinephrine challenge in sepsis: An empiric approach to catecholamines
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.
Cystic Fibrosis pulmonary exacerbation
CONTENTS Definition of a CF respiratory exacerbation Evaluation of respiratory deterioration in CF Management CFTR-directed therapies Antibiotic therapy Airway clearance Bronchodilator Respiratory support (HFNC, NIV, intubation) Nutritional support Bowel regimen Glycemic control Physical therapy (Steroid not indicated) Other topics related to CF Hemoptysis in CF Pneumothorax in CF Cirrhosis in CF Burkholderia cepacia complex Nontuberculous […]
EM Nerd-The Case of the Tarnished Standard
Anyone who has spent some time in a cardiac intensive care unit understands the physiologic appeal of the intra-aortic balloon pump (IABP). Anecdotally its use improves multiple clinical endpoints that for years have been considered surrogates for patient important outcomes. And yet, despite these physiologic advantages when examined in a rigorous fashion, IABPs have failed […]
Approach to pulmonary infection
CONTENTS tests & approaches Approach to pulmonary infections Infectious disease history 12 organisms to consider Selected radiological associations Noninvasive infectious evaluation Bronchoscopy: tests to consider Antibiotic selection Animal exposures Selected diagnostic tests: Beta-D-glucan Galactomannan Atypical lymphocytosis specific immunocompromising disorders HIV Kaposi sarcoma (KS) Pulmonary hypertension due to HIV ➡️ IRIS (immune reconstitution inflammatory syndrome) Transplantation […]
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