Category: Critical Care
Posted: 1/11/2011 by Mike Winters, MBA, MD
(Updated: 10/6/2024)
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Dexmedetomidine for Sedation in Acute Neurologic Disease
Mirski MA, Lewin JL. Sedation and analgesia in acute neurologic disease. Curr Opin Crit Care 2010; 16:81-91
Category: Critical Care
Keywords: PRES, hypertensive crisis, seizures, visual loss, ecclampsia, hypertensive emergency, cyclopsporine, tacrolimus (PubMed Search)
Posted: 1/4/2011 by Haney Mallemat, MD
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Posterior reversible encephalopathy syndrome (PRES) is a syndrome of visual loss, headache, altered mental status, and seizures, typically with severe hypertension. PRES usually occurs with hypertensive encephalopathy or ecclampsia, although cyclosporin and tacrolimus use have been implicated.
PRES is due to a combination of endothelial damage, impaired auto-regulation and increased cerebral perfusion pressure. Classic CT and MRI findings are parietal-occipital, cerebellar, or brainstem cortical and subcortical edema.
Early recognition and symptomatic treatment is key; IV anti-hypertensives (hypertensive encephalopathy), anti-epileptics (seizures), IV magnesium and emergent delivery (ecclampsia), and discontinuing offending medications (cyclosporin and tacrolimus).
With treatment, partial to complete recovery is normal, although residual neurological and visual deficits may persist.
Pula, J. Posterior reversible encephalopathy syndrome. Current Opinion in Ophthalmology. 2008 vol. 19 (6) pp. 479-84
Category: Critical Care
Posted: 12/28/2010 by Mike Winters, MBA, MD
Click here to contact Mike Winters, MBA, MD
Vancomycin Dosing in the Critically Ill Obese Patient
Medico CJ, Walsh P. Pharmacotherapy in the critically ill obese patient. Crit Care Clin 2010; 26:679-88.
Category: Critical Care
Keywords: thrombocytopenia, critically0ill, sepsis, death, mortality, prognosis (PubMed Search)
Posted: 12/21/2010 by Haney Mallemat, MD
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The incidence and prevalence of thrombocytopenia in the ICU is poorly defined however, it has been found to be an independent predictor of death in the critically-ill. Increased mortality does not appear to be related to bleeding complications. On the other hand, survivors of critical illness tend to recover platelet faster as compared to non-survivors.
Thrombocytopenia in the critically-ill is a marker for systemic inflammation/infection although the exact mechanisms are unknown. Common risk factors associated with thrombocytopenia in the ICU population are:
Sepsis
Renal failure
High-illness severity
Organ dysfunction
Bottom line: Thrombocytopenia in the critically-ill is associated with increased mortality.
Hui, P., The Frequency and Clinical Significance of Thrombocytopenia Complicating Critical Illness: A Systematic Review. Chest. 2010 Nov 11. [Epub ahead of print]
Category: Critical Care
Posted: 12/15/2010 by Mike Winters, MBA, MD
(Updated: 10/6/2024)
Click here to contact Mike Winters, MBA, MD
The Importance of Antibiotic Timing for Sepsis and Septic Shock
Funk DJ, Kumar A. Antimicrobial therapy for life-threatening infections: Speed is life. Crit Care Clin 2011; 27:53-76.
Category: Critical Care
Keywords: Antibiotics, linezolid, serotonin syndrome, delirium, critical care (PubMed Search)
Posted: 12/7/2010 by Haney Mallemat, MD
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Linezolid is used for gram-positive infections resistant to conventional therapy (e.g., Vancomycin-resistant enterococcus and Methicillin Resistant Staph Aureus). Linezolid is an oxazolidinone, but more importantly it is a weak monoamine oxidase inhibitor (MAOI) and serotonin syndrome (e.g., altered mental status, neuromuscular abnormalities, autonomic instability) may occur when combined with selective serotonin re-uptake inhibitors (SSRIs) or with recent discontinuation of SSRI.
Be aware that the following drugs can precipitate serotonin syndrome when combined with Linezolid:
Mirtazpine Buproprion Fentanyl
Trazodone Buspirone Bromocryptine
Levodopa Lithium Amphetamines
Cocaine Codeine Reserpine
Ergots MAOI's
Narita, M. Linezolid-Associated Peripheral and Optic Neuropathy, Lactic Acidosis, and Serotonin Syndrome Pharmacotherapy (2007) vol. 27 (8) pp. 1189-97
Category: Critical Care
Posted: 11/30/2010 by Mike Winters, MBA, MD
(Updated: 10/6/2024)
Click here to contact Mike Winters, MBA, MD
Beware Trendelenburg Positioning in the Critically Ill Obese Patient
Rahman O, Willis L. Vascular procedures in the critically ill obese patient. Crit Care Clin 2010;26:647-60.
Category: Critical Care
Keywords: Status epilepticus, non-convulsive, altered mental status, seizure, critical care, ICU, neurology (PubMed Search)
Posted: 11/23/2010 by Haney Mallemat, MD
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Non-Convulsive Status Epilepticus (NCSE) is generally under reported. An ICU study found 10% admissions for altered mental status (AMS) were eventually diagnosed as NCSE.
Pearls:
- Include NCSE in the AMS differential
- NCSE may occur with or without convulsive seizures
- Difficult to distinguish from a post-ictal state (14% of convulsive seizures convert to
NCSE)
- Reported mortality is up to 44%
Consider NCSE when:
- Seizure history / recent seizures
- Post-ictal period >1 hour
- Odd behaviors (e.g., chewing, blinking, personality change) and abnormal eye
movements (86% specific)
- AMS without structural, metabolic or traumatic etiology
- Patient intubated for status epilepticus
If you are unsure but suspicious of NCSE order a STAT EEG. Treat NCSE like a convulsive status.
Slattery, D. Seizures as a cause of altered mental status. Emerg Med Clin North Am. 2010 Aug;28(3):517-34.
Category: Critical Care
Posted: 11/16/2010 by Mike Winters, MBA, MD
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Positioning for Ventilated, Critically Ill Obese Patients
Ashburn DD, DeAntonio A, Reed MJ. Pulmonary system and obesity. Crit Care Clin 2010; 26:597-602
Category: Critical Care
Keywords: ultrasound, ocular, sonography, intracranial pressure, optic nerve sheath, ICP (PubMed Search)
Posted: 11/9/2010 by Haney Mallemat, MD
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Ocular sonography is a fast, simple, and non-invasive tool to detect elevated intracranial pressure (ICP) by measuring the optic nerve sheath diameter (ONSD). Several studies have shown a positive correlation between increased ONSD (>5.7mm) and elevated ICP (>20mmHg). Although ultrasound may not replace CT or MRI to diagnose the cause of the increased ICP, its use as a triage tool can expedite these tests.
The technique:
Please see the references below for more information and, as with any new technique please consult local experts prior to making clinical decisions.
http://www.sonoguide.com/smparts_ocular.html
Soldatos, T. et al. Optic nerve sonography in the diagnostic evaluation of adult brain injury. Crit Care. 2008; 12(3): R67. Epub 2008 May 13.
Category: Critical Care
Posted: 11/2/2010 by Mike Winters, MBA, MD
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Ventilation Pearls in the Post-Cardiac Arrest Patient
Peberdy MA, Callaway CW, Neumar RW, et al. Post cardiac arrest care: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122(S3):S768-S786.
Category: Critical Care
Keywords: delirium, dementia, ICU, (PubMed Search)
Posted: 10/25/2010 by Haney Mallemat, MD
(Updated: 10/6/2024)
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Increasing literature demonstrates ICU delirium is bad. Delirium in mechanically ventilated patients is an independent predictor for long-term cognitive defects (e.g., managing money, following detailed instructions, reading maps, and developing dementia). The cited study found 80% of patients with ICU delirium had cognitive dysfunction at three months, and 70% had residual dysfunction at one year (33% had severe dysfunction).
You must be aggressive to prevent delirium:
- Implement daily assessment tools (e.g., CAM-ICU)
- Daily awakening and spontaneous breathing trials
- Early patient mobilization
- Aggressive pharmacological treatment of delirium
- For more information: www.icudelirium.org
Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Girard, T., et al. Crit Care Med. 2010 Jul;38(7):1513-20.
Category: Critical Care
Posted: 10/19/2010 by Mike Winters, MBA, MD
(Updated: 10/6/2024)
Click here to contact Mike Winters, MBA, MD
Ketamine for RSI in Hemodynamically Unstable ED Patients
Morris C, et al. Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent? Anaesthesia 2009; 64: 532-9.
Category: Critical Care
Keywords: asthma, heliox, airway (PubMed Search)
Posted: 10/12/2010 by Haney Mallemat, MD
(Updated: 10/6/2024)
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Heliox is a mixture of oxygen and helium resulting in a gas less dense than air. In asthma, airway resistance causes turbulent airflow which increases the work of breathing. Heliox reduces airway resistance by increasing laminar airflow.
Benefits:
Better lung mechanics
Improved nebulizer delivery
Few known side-effects/complications
Drawbacks:
Expensive
Contraindicated in hypoxemic patients.
Paucity of large prospective randomized trials.
McGarvey JM, Pollack CV. Heliox in Airway Management. Emerg Med Clin North Am. 2008 Nov;26(4):905-20, viii.
Category: Critical Care
Keywords: endotracheal intubation, medication, acls, resuscitation (PubMed Search)
Posted: 10/7/2010 by Ellen Lemkin, MD, PharmD
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EMS in Maryland has REMOVED endotracheal medication administration from its ADULT protocols
This is due to:
Category: Critical Care
Posted: 10/5/2010 by Mike Winters, MBA, MD
(Updated: 10/6/2024)
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Respiratory Distress in the Ventilated ED Patient
Santanilla JI, Daniel B, Yeow ME. Mechanical ventilation. Emerg Med Clin N Am 2008;26:849-862.
Category: Critical Care
Keywords: HAART HIV AIDS Critical illness (PubMed Search)
Posted: 9/27/2010 by Haney Mallemat, MD
(Emailed: 9/28/2010)
(Updated: 9/28/2010)
Click here to contact Haney Mallemat, MD
While you should always involve ID consultants when managing critically-ill HIV/AIDS patients on HAART, consider this; sub-therapeutic levels of anti-retrovirals may promote HIV resistance, potentially invalidating a class of drug for future use. Therefore, it may be advantageous to discontinue the drug(s) during critical-illness to avoid resistance.
Two examples leading to sub-therapeutic HAART levels in critical-illness:
Current issues in critical care of the human immunodeficiency virus-infected patient. Morris A, Masur H, Huang L Crit Care Med. 2006 Jan;34(1):42-9.
Category: Critical Care
Posted: 9/21/2010 by Mike Winters, MBA, MD
(Updated: 10/6/2024)
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Life-threatening Bleeding in Hemophilia A Patients
Singleton T, Kruse-Jarres R, Leissinger C. Emergency department care for patients with Hemophilia and Von Willebrand Disease. JEM 2010; 39:158-65.
Category: Critical Care
Keywords: Necrotizing Soft Tissue Infections, sepsis, critical care, surgery (PubMed Search)
Posted: 9/13/2010 by Haney Mallemat, MD
(Emailed: 9/14/2010)
(Updated: 9/14/2010)
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(Sorry for the previously mislabeled pearl...)
Necrotizing soft tissue infections (NSTI) are on the rise and, despite improved surgical and critical care, over the years there has only been a mild reduction in mortality. Survival is associated with early diagnosis and treatment. Unfortunately, NSTI are not always obvious because deeper tissues made be involved first. Despite a validated scoring system and better radiology, our clinical suspicion still rules and relies on a meticulous history and physical exam.
Here are some subtle signs of NSTI:
Pain out of proportion to exam
Edema beyond region of erythema
Skin anesthesia
Skin erythema and/or hyperthermia
Epidemolysis
Skin bronzing
If NSTI is suspected, be vigilant! Start broad-spectrum antibiotics, begin appropriate resuscitation and involve your surgeons early.
Necrotizing soft tissue infections in the intensive care unit. Crit Care Med. 2010 Sep; 38: S460-8. Phan HH, et al.
Category: Critical Care
Posted: 9/7/2010 by Mike Winters, MBA, MD
(Updated: 10/6/2024)
Click here to contact Mike Winters, MBA, MD
Pulmonary Contusion and Ventilator Management
Kiraly L, Schreiber M. Management of the crushed chest. Crit Care Med 2010; 38(S):S469-S477.