Introduction . Community-acquired pneumonia (CAP) remains the leading cause of infectious disease death in developed countries. Described by Sir William Osler as “captain of the men of death,” it dates back to antiquity. However, we are only beginning to understand the best ways to treat it. . Part 1: The Pneumococcal meningitis story . Ceftriaxone […]
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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 […]
Acute Kidney Injury
CONTENTS Rapid Reference: Approach to AKI 🚀 Definition & significance of AKI Causes of AKI Nephrotoxins Evaluation of the cause of AKI Tests not to order Tests to evaluate the cause of AKI Approach to oliguria Management of AKI Dose-adjust renally cleared medications Hemodynamic optimization Treatment of acidosis Dialysis Phosphate binder Related Uremic encephalopathy Dialysis […]
PulmCrit- Killer resuscitation: Abdominal hypertension as an occult driver of multiorgan failure
Introduction with a clinical conundrum A 66-year-old man is transferred from an outside hospital due to inability to be liberated from the ventilator. He presented a week earlier with pneumonia and sepsis. He received six liters of fluid initially, and has been running net positive 1-2 liters daily since then (for a total of about […]
Elevated intracranial pressure (ICP)
CONTENTS Rapid Reference 🚀 Physiology Hydrocephalus Different types of edema Focal versus global ICP elevation Causes of ICP elevation Diagnosis Clinical manifestations Ultrasound evaluation for ICP elevation Neuroimaging Single measurement of ICP with lumbar puncture ICP monitoring Indications for continuous ICP monitoring Techniques for continuous ICP monitoring ICP value interpretation CPP value interpretation ICP waveform […]
Paroxysmal sympathetic hyperactivity (PSH)
CONTENTS Introduction Epidemiology Clinical findings Differential diagnosis Approach to the diagnosis Treatment Supportive care Medical therapy overview Abortive therapy Preventative therapy Podcast Questions & discussion Pitfalls basics Paroxysmal sympathetic hyperactivity (PSH) is a pattern of recurrent bursts of dysregulated sympathetic activity, resulting from severe brain injury. These episodes of sympathetic activation are short, dramatic, and […]
The Complexity of Simple – Bringing Order to Complex Systems by Chris Hicks
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EMCrit Shadowboxing Case 6 – A Respiratory Case along with Extra Commentary from Mae West
A pulm-crit shadowboxing case
Liberation from the ventilator
CONTENTS Rapid Reference: Optimization & items to consider prior to extubation 🚀 Spontaneous Breathing Trial (SBT) If the patient fails the SBT Causes of failed SBT Investigation If the patient passes the SBT A trial of extubation Post-extubation support Timing of tracheostomy Some additional concepts Unplanned extubation Nocturnal extubation Understanding & navigating the obesity quagmire […]
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.
Necrotizing fasciitis
CONTENTS Basics Diagnosis Clinical presentation Laboratory abnormalities Ultrasonography Imaging Bedside surgical exploration Management Sepsis resuscitation Antibiotics Surgical debridement Therapy for simultaneous toxic shock syndrome Extra oxygen Podcast Questions & discussion Pitfalls general concept The fascia is a thin layer of connective tissue beneath the skin. Infection can spread rapidly along this fascial layer. Severe infection […]
Ventricular arrhythmias
CONTENTS approach to wide-complex monomorphic tachycardia Diagnostic approach to wide complex tachycardia [1] Consider pretest probability for VT [2] Compare to old ECG if available [3] Initiation of wide complex tachycardia [4] Signs of potential VT mimic [5] Evidence of AV dissociation? [6] Morphology in Leads II & aVR Morphology rules [7a] RBBB-type [7b] LBBB-type […]
Acute Pancreatitis (including hypertriglyceridemic pancreatitis)
CONTENTS Rapid Reference 🚀 Diagnosis Clinical findings Laboratory studies (lipase) Radiology Diagnostic criteria Evaluating the cause of pancreatitis Risk stratification – who needs ICU? Treatment General principle: pancreatoseptic equivalence Treatment of causative factors ERCP? Resuscitation Analgesia Nutrition Non-hypertriglyceridemic pancreatitis Hypertriglyceridemic pancreatitis Prophylactic & early antibiotics Fluid collections & infected necrosis Abdominal compartment syndrome Hemorrhage Hypertriglyceridemic […]
Submassive PE: Are we treating it backwards?
Introduction 0 Submassive PE can be challenging. Most patients do fine with heparin, but occasional patients suddenly arrest and others are left with longstanding pulmonary hypertension.1 Thrombolytics generally cause dramatic improvement, but may cause hemorrhage as well. Recent studies may seem to point in opposite directions. 0 Background: Heparin vs. Alteplase 0 Treatment centers around […]
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 […]
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