Critical Care Notes

A man in his 50s seeks the ED for the umpteenth time since his abdo pain started a few years ago. He says that it’s his gallbladder, surgery has been denied because of diffuse pain and normal blood tests. Today CRP 9, Leukocytes 11. #POCUS He got his operation the next day. #EMIMCC

I do this pretty regularly

Expanding the horizon: The case for point-of-care... : Journal of the American Association of Nurse Practitioners enhanced diagnostic accuracy, faster decision-making, and improved patient satisfaction. With growing access to affordable handheld devices and expanding educational opportunities, POCUS is becoming i...

Point-of-care ultrasound is being used by an increasing number of nurse practitioners, but its utility is not limited to the ICU, nor even to Acute Care.

journals.lww.com/jaanp/abstra...

a man wearing sunglasses and a green shirt with breaking bobby bones on the bottom ALT: a man wearing sunglasses and a green shirt with breaking bobby bones on the bottom

rapidly pushing IV calcium may cause:

😦 vasodilation, bradycardia, hypotension
😦 nausea/vomiting, flushing

if patients are conscious, this can make them feel horrible

if the patient is obtunded & not intubated, emesis can be a big problem

whenever possible, give IV Ca slowly #EMIMCC

The other thing to remember is that patients in HFNC typically benefit more from “flow” than FiO2. So wean the FiO2 before the flow.

And remember, ST is often compensatory. Don’t slow it down blindly.

“But WHY did they fail?” All too often I get, “they failed SBT” from someone who also wasn’t there, and that’s that. Do it again and see for yourself. Often you can get them off the vent after all.

Big news for lung ultrasound #POCUS

I sadly see this not rarely. Especially with overworked interns. They run out of time and rather than admit this, and risk being perceived as failing, they lie. And they ALWAYS get caught.

I’ll add to this, communicate when you want to be called. Don’t just start NE with a MAP goal>65, add, “call me if you get to X.” This prevents you getting busy and checking back to find that they’re almost maxed.

Occult VF in Cardiac Arrest: 5.3% of patients with cardiac arrest showed VF on echo but ECG w/ PEA/asystole

Study does not show improved outcomes but not powered to do so

Strong argument for intra-arrest echo as it can dramatically change management

#EMIMCC

YouTube video by EMSwami Advice for Interns 2: Listen to The Nurses #emergencymedicine #internship #residents

Advice for New Trainees #2: Listen to your nurses

Don’t mistake your short time as a doctor as equivalent clinically to their years and decades of experience

If a nurse asks you to reevaluate a patient, GO TO THE BEDSIDE AND RE-EVALUTE THE PATIENT, EVERY TIME.

youtube.com/shorts/c0o5F...
#EMIMCC

Might we be correcting hyponatremia too slowly? May our patients be suffering because we're too fearful of the risk of central pontine myelinolysis? Here's data that may challenge our regular approach. Hat tip to the authors.
eddyjoemd.com/foamed

Interesting. Had never thought of this before. How many other things in medicine to we get wrong because if assumptions?

This is what we were waiting for. A direct comparison between apixaban and rivaroxaban for the treatment of acute VTE. Apixaban reduces bleeding risk in the first 3 months by >50%!

Practice changing investigator-initiated RCT.

#ISTH2025

Recently had @ebtapper.bsky.social on the Critical Care Scenarios podcast talking GI and this topic came up.

icuscenarios.com/lightning-ro...

Totally agree regarding docusate. I start bowel regimen (typically senna) on admission. Like pain, much easier to get ahead of than to fix when out of control. Escalate as needed. BM at least every 3 days.

Not anesthesia but all my attendings are. We typically reverse prior to extubation in cases like you mention.

New lesson in the POCUS course: Abdominal ultrasound!

#medsky #emimcc #POCUS

Mottling is one of this signs that gets me real worried.

beta-blocker in sepsis trials continue to mystify me

you have patients on reasonable doses of pressor (0.5 mcg/kg/min norepi equivalent) with an average MAP ~80 (mean diastolic BP ~60!)

you're worried about catecholamine toxicity

instead of reducing the pressors you add a beta-blocker😳 #EMIMCC

Don’t be distracted by the obvious pleural yuck…

My students know well of my disdain for the d-diner…

About all it’s good for.

From MD calc: “The model should be applied only after a history and physical suggests that venous thromboembolism is a diagnostic possibility. it should not be applied to all patients with chest pain or dyspnea or to all patients with leg pain or swelling. This is the most common mistake made. Also, never never do the D-dimer first [before history and physical exam]. The monster in the box is that the D-dimer is done first and is positive (as it is for many patients with non-VTE conditions)”

No, no. Wells is the scientist’s name, you’re referring to Wells’ monster. #emimcc

Anyone ever done peer review for Optum InterQual? I was approached about doing some reviews but not sure what to make of it. Sounds good, they send you material in your area of expertise and you review it for accuracy. I’ve done similar work before but never heard of this particular company.

Carolina Maciel on critical care EEG

icuscenarios.com/episode-86-e...

#medsky #emimcc

Systematic combined noncontrast CT–CT angiography in the management of unexplained nontraumatic coma Nontraumatic impaired consciousness is a common issue in emergency departments with a serious but widely variable prognosis.The aim of this prospectiv…

Basilar artery occlusion accounts for ≈10% of nontraumatic causes of coma

Unconscious without a good explanation? CT head WITH ANGIOGRAPHY is a must❗️

www.sciencedirect.com/science/arti...

#EMIMCC

ICU Snapshots:

- How is this new patient in room 6 doing? I have not seen him yet
- Blood gases look ok. Po2 96, Pco2 35
- OK, I will see him in 5’

5’ later: I saw the (non-invasive) vent screen before entering the room

ICU Hemodynamics:

If you are managing patients with #vasoplegicshock, this is a nice review article: