Category: Critical Care
Posted: 3/6/2012 by Mike Winters, MBA, MD
(Updated: 2/17/2025)
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Preventing VAP in the Intubated ED Patient
Ramirez P, et al. Measures to prevent nosocomial infections during mechanical ventilation. Curr Opin Crit Care 2012;18:86-92.
Category: Critical Care
Keywords: VAD, ventricular assist device, hear failure, shock, hemodynamics (PubMed Search)
Posted: 2/28/2012 by Haney Mallemat, MD
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Ventricular assist devices (VAD) pump blood from the left, right or both ventricles for patients in severe ventricular failure.
VADs may be placed temporarily (as a bridge to transplant) or permanently in patients who are not transplant candidates (also known as Destination Therapy)
Certain types of VADs continuously pump blood in a non-pulsatile fashion. In these cases, a patient may be perfusing normally without a palpable pulse.
Familiarity with potential VAD complications is important as a patient with a VAD may be presenting to an ED near you. Complications include:
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Category: Critical Care
Posted: 2/21/2012 by Mike Winters, MBA, MD
(Updated: 2/17/2025)
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Ice-Cold Crystalloid for Therapeutic Hypothermia
Arulkumaran N, Ball SJ. Use of ice-cold crystalloid for inducing mild therapeutic hypothermia following out-of-hospital cardiac arrest. Resuscitation 2012;83:151-8.
Category: Critical Care
Keywords: pericardial tampaonde, shock, tamponade, fluids, hypoperfusion (PubMed Search)
Posted: 2/13/2012 by Haney Mallemat, MD
(Updated: 2/15/2012)
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A fluid bolus is often the first-line therapy for patients with pericardial tamponade. A fluid bolus, however, may not always improve hemodynamics.
The cardiac index of forty-nine patients with cardiac tamponade was assessed before and after a 500 cc normal saline bolus:
Bottom-line: A fluid bolus may a reasonable first choice in a hypotensive patient with tamponade, but remember that fluid boluses may not always work. Attempts at fluid resuscitation should never delay definitive treatment with pericardiocentesis.
Sagrista-Sauleda, et al. Hemodynamic effects of volume expansion in patients with cardiac tamponade. Circulation 2008; 117:1545
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Category: Critical Care
Posted: 2/7/2012 by Mike Winters, MBA, MD
(Updated: 2/17/2025)
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ECMO for ARDS and Refractory Hypoxemia
Brodie D, Bacchetta M. Extracorporeal membrane oxygenation for ARDS is adults. NEJM 2011;365:1905-14.
Category: Critical Care
Posted: 1/31/2012 by Haney Mallemat, MD
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AGE occurs when gas bubbles enter arteries or veins; AGE may cause clinical symptoms even with very small volumes of air.
Air enters the circulatory system via:
· Barotrauma – Alveolar injury allows air to enter systemic bloodstream; occurs in divers following rapid ascent after breath holding, during mechanical ventilation, chest tube placement, or bronchoscopy
· Decompression sickness – Dissolved gas precipitates out of bloodstream as bubbles; typically following scuba diving without appropriate time to ascend or prolonged flying in unpressurized aircrafts
· Direct injection of air into arterial or venous circulation – Examples include accidental IV injection of air, needle biopsy of lung, or aspiration of air during central line placement
Serious clinical manifestations include:
· Neurologic changes - loss of consciousness, confusion, or focal neurological deficits
· Hemodynamic changes – hypotension, arrhythmias, cardiac ischemia, or cardiac arrest.
· Respiratory changes – obstruction of pulmonary circulation, pulmonary edema, or hypoxemia
Treatment:
· Strict attention to ABC’s using high-flow O2.
· Keep head of bed elevated to minimize/reduce cerebral edema.
· Hyperbaric Oxygen (HBO) therapy is recommended for neurological manifestations or cardiovascular instability. Good outcomes associated with shorter intervals from air embolism to HBO. Typically only 1 to 2 treatments are needed; occasionally additional treatments are necessary.
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Category: Critical Care
Posted: 1/24/2012 by Mike Winters, MBA, MD
(Updated: 2/17/2025)
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SAH and Pulmonary Edema - Think Twice About Diuresis!
Scalfani MT, Diringer MN. Year in review 2010: Critical Care - neurocritical care. Crit Care 2011;15:237.
Category: Critical Care
Keywords: fungal, endopthalmitis, ocular, critically ill, systemic infection, immunosupression, IVDA (PubMed Search)
Posted: 1/17/2012 by Haney Mallemat, MD
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Fungal endopthalmitis is an intraocular infection of the aqueous and/or vitreous humor secondary to fungal pathogens; Candida and Aspergillus species are the most common pathogens.
Risk factors: intravenous drug abuse (#1 risk factor), critical illness, systemic fungal infection, immunosuppression (from cancer or medications), diabetes, and alcoholism.
Have a high-index of suspicion for endopthalmitis when patients with systemic fungal disease have visual symptoms; endopthalmitis is present in up to 33% of patients with systemic fungal disease.
Symptoms include:
Inspection of both the anterior and posterior chamber is essential to during evaluation; several small yellow-white circular or “fluffy” lesions with surrounding hemorrhage are demonstrated.
Definitive diagnosis made by vitreous biopsy, culture, or PCR; presumptive treatment is acceptable if systemic fungal disease has been demonstrated.
Treatment with Amphotericin B or Voriconazole may be used for broad-spectrum fungal coverage until specific culture and sensitivities return.
Shah CP, McKey J, Spirn MJ, Maguire J. Ocular candidiasis: a review. Br J Ophthalmol. Apr 2008;92(4):466-8.
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Category: Critical Care
Posted: 1/10/2012 by Mike Winters, MBA, MD
(Updated: 2/17/2025)
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Hypertonic Saline for Intracranial Hypertension
Torre-Healy A, Marko NF, Weil RJ. Hyperosmolar therapy for intracranial hypertension. Neurocrit Care 2011.
Category: Critical Care
Keywords: blunt trauma, vascular inury, anticoagulation, thrombosis, emboli (PubMed Search)
Posted: 1/3/2012 by Haney Mallemat, MD
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Carotid or vertebral artery injury following blunt trauma is a rare (%1 of blunt trauma), but a potentially serious injury potentially causing stroke and long-term disability.
Injury leads to an intimal tear becoming a nidus for platelet aggregation; thrombosis and/or distal emboli may subsequently develop.
Mechanisms of injury include:
Symptoms of carotid injury may include contralateral sensorimotor deficits; Symptoms of vertebral injury may include ipsilateral facial pain and numbness, headache, ataxia, or dizziness.
Angiography is the diagnostic “gold standard” but these days a 16-slice CT angiography (or greater) is a reliable screening tool.
Anticoagulation with heparin is the treatment of choice for severe injury, if there are no contraindications (e.g., intracranial bleeding). Anti-platelet drugs may be acceptable in certain cases.
Kim YK, Schulman S. Cervical artery dissection: pathology, epidemiology and management. Thromb Res. Apr 2009;123(6):810-21.
Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. Mar 22 2001;344(12):898-906.
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Category: Critical Care
Posted: 12/27/2011 by Mike Winters, MBA, MD
(Updated: 2/17/2025)
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VBG to Assess Respiratory Function?
Kelly AM. Can venous blood gas analysis replace arterial in emergency medical care? Emerg Med Australasia 2010;22:493-498.
Category: Critical Care
Keywords: amiodarone, lung toxicity, ARDS, infection, critical care (PubMed Search)
Posted: 12/20/2011 by Haney Mallemat, MD
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Amiodarone-induced lung toxicity (ALT) is a serious and sometimes fatal complication of amiodarone use.
Symptoms range from mild (e.g., dyspnea with exertion) to acute respiratory distress syndrome and risk of death.
ALT is secondary to either release of toxic oxygen radials that are directly toxic to the lung or the reaction is secondary to an indirect immunologic reaction.
Risk factors for ALT: use > 2 months, dose > 400mg/day, advanced age, or pre-existing lung injury
ALT is typically a diagnosis of exclusion so suspect ALT through a detailed history; physical exam and radiology are non-specific. Lung biopsy is the only confirmatory test.
Treat ALT by discontinuing the drug, steroids, and supportive care. In rare cases where amiodarone cannot be safely discontinued (i.e., life-threatening arrhythmia), dosage should be reduced and steroids added immediately.
Generally, ALT is reversible with a good prognosis.
Mahajan, V. et al Amiodarone induced acute interstitial pneumonitis.BMJ Case Rep. 2009;2009.
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Category: Critical Care
Posted: 12/13/2011 by Mike Winters, MBA, MD
(Updated: 2/17/2025)
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The Crashing Patient with PAH
Rubenfire M, Bayram M, Hector-Wood Z. Pulmonary hypertension in the critical care setting: classification, pathophysiology, diagnosis, and management. Crit Care Clin 2007;23: 801-834.
Category: Critical Care
Posted: 12/6/2011 by Haney Mallemat, MD
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Up until recently, a tight-fitting mask was one of the only ways to deliver non-invasive positive-pressure ventilation.
High-flow nasal cannulas (HFNC) have been adapted from use in neonates to adults to deliver continuous positive airway pressure (CPAP).
HFNC provides continuous, high-flow (up to 60 liters), and humidified-oxygen via nasal cannula providing positive pressure to the pharynx and hypopharynx. Patients tolerate it well and it is less claustrophobic than tight-fitting masks.
HFNC does not generate the same amount of pressure as CPAP so it may be best utilized as an intermediate step between low-flow oxygen (i.e., traditional nasal cannula) and non-invasive positive pressure ventilation with tight-fitting masks.
Check with your respiratory department if these devices are locally available.
Kernick, j. What is the evidence for the use of high flow nasal cannula oxygen in adult patients admitted to critical care units? A systematic review. Aust Crit Care. 2010 May;23(2):53-70. Epub 2010 Mar 5.
Parke, R. A preliminary randomized controlled trial to assess effectiveness of nasal high-flow oxygen in intensive care patients. Respir Care. 2011 Mar;56(3):265-70. Epub 2011 Jan 21.
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Category: Critical Care
Posted: 11/29/2011 by Mike Winters, MBA, MD
(Updated: 2/17/2025)
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Hypotension in the PAH Patient
Rubenfire M, Bayram M, Hector-Wood Z. Pulmonary hypertension in the critical care setting: classification, pathophysiology, diagnosis, and management. Crit Care Clin 2007;23: 801-834.
Category: Critical Care
Keywords: hypotension, shock, ultrasound, hi map (PubMed Search)
Posted: 11/22/2011 by Haney Mallemat, MD
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Determining the exact etiology of hypotension / shock can sometimes be difficult in the Emergency Department.
The Rapid Ultrasound for Shock / Hypotension (RUSH) exam is a sequential, 5 step-protocol (typically requiring less than 2 minutes) that can be used to determine the cause(s) of hypotension.
The mnemonic for the exam is “HI MAP”, and is easy to remember because a "HI MAP" is our goal with hypotensive patients.
H - Heart (parasternal and four-chamber views)
I - Inferior Vena Cava (for volume responsiveness)
M - Morrison’s pouch (i.e., FAST exam) and views of thorax (looking for free fluid)
A - Aortic Aneurysm (ruptured abdominal aneurysm)
P - Pneumothorax (i.e., Tension PTX)
Refer to the link for a more detailed discussion and podcast from the creators of this exam: emcrit.org/rush-exam
Category: Critical Care
Posted: 11/15/2011 by Mike Winters, MBA, MD
(Updated: 2/17/2025)
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Hypertensive Emergency Pearls
Marik PE, Rivera R. Hypertensive emergencies: an update. Curr Opin Crit Care 2011; 17:569-80.
Category: Critical Care
Keywords: tamponade, critical care, intubation, positive pressure, PEA arrest (PubMed Search)
Posted: 11/8/2011 by Haney Mallemat, MD
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Positive-pressure ventilation (e.g., mechanical ventilation) increases intrathoracic pressure potentially reducing venous return, right-ventricular filling, and cardiac output.
Pericardial tamponade similarly causes hemodynamic compromise through increased pericardial pressure which reduces right-ventricular filling and cardiac output.
When mechanically ventilating a patient with known or suspected pericardial tamponade the mechanisms above may be additive, causing cardiovascular collapse and possibly PEA arrest.
For the patient with known or suspected pericardial tamponade consider draining the pericardial effusion prior to intubation or delaying intubation until absolutely necessary.
If intubation is unavoidable, consider maintaining the intrathoracic pressure as low as possible (by keeping the PEEP and tidal volumes to a minimum) to ensure adequate cardiac filling and cardiac output.
Ho, A. et. al. Timing of tracheal intubation in traumatic cardiac tamponade: A word of caution. Resuscitation, 80(2), 272–274.
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Category: Critical Care
Posted: 11/1/2011 by Mike Winters, MBA, MD
(Updated: 2/17/2025)
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Mechanical Ventilation in Patients with Pulmonary HTN
Category: Critical Care
Keywords: xigris, activated protein C, sepsis, multi-organ failure, resuscitation (PubMed Search)
Posted: 10/25/2011 by Haney Mallemat, MD
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On October 25, 2011, Eli Lilly announced a voluntary-recall of activated drotrecogin alfa (Xigris) following a recent trial (PROWESS-SHOCK), which demonstrated no survival benefit when using the drug when compared to placebo.
Activated drotrecogin alfa is a recombinant form of human activated protein C previously recommended for adults with severe sepsis and a high-risk of death (APACHE II > 25 or multi-organ failure); it is included in the 2008 International Sepsis Guidelines (Grade 2b recommendation).
The PROWESS-SHOCK trial reported an all-cause mortality rate of 26.4% in the drotrecogin alfa group compared with 24.2% in the placebo group; this difference was not statistically significant.
Interestingly, the study also found that severe bleeding (the drug's main side-effect) was found to be 1.2% in the activated drotrecogin alfa group compared to 1.0% for the placebo group (also non-significant) suggesting it does not increase the risk of bleeding as it had previously been reported.
Hospitals should revise their sepsis guidelines based on this recent news.
www.medscape.com/viewarticle/752169?sssdmh=dm1.728719&src=nl_newsalert
Dellinger, R. P., et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Critical Care Medicine, 36(1), 296–327. doi:10.1097/01.CCM.0000298158.12101.41
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