Critical Care Notes

Kwame gives us the skinny on practicing medicine abroad. How do you do it right? Who pays? How do you get started? icuscenarios.com/lightning-ro... #medsky #emimcc

Anyone in medical (including APPs) education using AI in assignments? I don’t mean using it to grade or create assignments or content, but having students do something with AI? #MedEd

Confused about steroids in the ICU? This week on the podcast, we talk to David Janz about who needs them, which ones to use, and which dose. icuscenarios.com/lightning-ro...

DOPES Mnemonic: structured approach to deal with hypoxia in the ventilated patient Displacement, Obstruction, Patient factors (ie PE, PTX), Equipment Issues, Stacked Breaths. Address all of these factors in parallel youtube.com/shorts/rwumW... #EMIMCC

Just updated the IBCC chapter on cholecystitis & cholangitis. These patients are often initially triaged to the ICU. Understanding these diseases can help us direct patients to interventions they need. Let’s talk about four pearls 😁 chapter: emcrit.org/ibcc/biliary... #EMIMCC

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

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...

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

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

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…

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

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:

as EM docs we'll always be looking after non sick patients. We hope the scissor between the very sick and not sick will be narrow in the future (letting other doctors to care for the not sick) but will not close for some years. Here's a tool to enjoy this part of the care emupdates.com/how/ #EMIMCC

#POCUS approach to shock states: Assessment of cardiogenic shock:

Assessment of obstructive shock:

Assessment of hypovolemic shock:

Me this morning when I overheard some nurses refer to Marroon 5 as “classic rock.”

It’s a good one coming up @critconcepts.bsky.social and I talk with @thinkingcc.bsky.social about hemodynamic interfaces in critical care. To listen to the whole episode, go to icuscenarios.com or subscribe to Critical Care Scenarios wherever you get your favorite podcasts

Next week on the podcast, @critconcepts.bsky.social and I talk with @thinkingcc.bsky.social about hemodynamic interfaces in critical care. To listen to the whole episode, go to icuscenarios.com or subscribe to Critical Care Scenarios wherever you get your favorite podcasts.

Did you read the OVISS study in @jama.com? It showed that earlier initiation of vasopressin (V) in septic shock is associated with ⬇️ mortality I am a bit biased here; V is one of my favorite drugs and I do start it very early. However, it is a big leap to infer causality from an observational study

100% this. And since there is no good definitive test for COPD exacerbation, you should rule everything else out first.

It’s always interesting hanging out with my non-ICU friends and hearing them return pages. Pro-tip: if you’re consulting a specialist, don’t start with the patient’s life story, start with the reason for the consult. Why should the (very busy) person keep listening to you?

Interesting approach. My rule of thumb has always been once you get goal BP, go back to whatever you were on before as that dose probably got you there, it just took a while to kick in.

Ok #POCUS crew, I’m giving a talk to some students coming up trying to convince them that POCUS is helpful outside of the ICU/ED. What are the go-to exams for hospital medicine, specialty clinic/primary care/women’s health?

Spending this morning in the Sim Lab with our Critical Care APP fellows working on an under appreciated part of critical care, delivering hard news and discussing palliative care.

If you've been thinking of subscribing to the Intensive Care Academy, now would be a clever time - until March 15, we're offering a 10% discount for new subscribers. Just use the code FEB25 at checkout. Tell your friends, tell your family...

We take care of numerous issues pertaining to the liver. Here is a framework for why these patients get so sick and what to do about it. 🎩 tip to the authors. eddyjoemd.com/foamed/

Yup youtu.be/BbNi_-wYXJE?...

need some bland, meaningless conclusions for your review article? use these! these conclusions are so nonspecific that they're perfectly applicable to any ICU topic 👌 you're welcome

open.substack.com/pub/pulmccm/...