Critical Care

A relaxing RCT

You sign out to the overnight team at midnight and stay an hour or so completing a laceration repair and finishing your charts.  It's been a chaotic afternoon and evening and the patina of COVID-19 didn’t make things any better. After your shift (and appropriate decontamination) you pass your hospital’s new resiliency resource room.  You wonder, “What would be more relaxing right now? Doing some deliberative coloring, petting a dog, or just heading home?”

To art line or not to art line?

You are working in a busy ED when a patient who is 54 arrives with an acute onset headache associated with syncope but no focal neurologic deficits.  His physical exam is unremarkable but his BP is mildly elevated at 175/80. The patient’s head CT is consistent with an aneurysmal subarachnoid hemorrhage.  You begin anti-hypertensive treatment, but wonder how reliable non-invasive blood pressure measurement is in this patient.

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Finding language when there are no words

During the current pandemic, physicians are findings themselves interfacing with the public and talking about topics they never thought they would have to consider.  One way to prepare for this is to develop a library of phrases ahead of time which can be used in the appropriate context. It can also be helpful to generate analogies to common objects/systems to assist the general public in understanding critical care concepts.

Goldilocks in the ICU: Oxygenation targets for mechanical ventilation

 

Like all medical therapies, we have learned that treatment with oxygen comes at a cost. The medical literature is replete with the detriments of hyperoxia in the management of myocardial infarction, acute stroke, cardiac arrest and septic shock. What is the optimal oxygenation target for critically ill patients requiring mechanical ventilation? Three landmark trials can guide us: Oxygen-ICU, ICU-ROX and LOCO2. The end to the oxygenation fairytale remains to be told, but perhaps Goldilocks is “just right.”  

Hands on defibrillation

A 58 year old male arrives to the ED in cardiac arrest.  CPR is in progress and you are concerned about the amount of time needed prior to defibrillation to stop compressions, ensure all personnel are not touching the patient or the bed, delivering the shock, and then restarting CPR.  It occurs to you that the pads could deliver a shock while CPR is in progress, but wonder about the safety and efficacy.

Mastering mechanical ventilation: what is mechanical power?

Over the last three decades since the introduction of the term ventilator-induced lung injury (VILI), we have recognized that positive pressure mechanical ventilation can injure the lungs. It is widely recognized that the cornerstone of lung protective ventilation requires control of tidal volume and transpulmonary pressure. On the other hand, there has been considerably less focus on the impact of respiratory rate and flow on VILI. Mechanical power unites the causes of ventilator-induced lung injury in a single variable that incorporates both the elastic and resistive load of the positive pressure breath.6 In other words, mechanical power quantifies the energy delivered to the lung during each positive pressure breath by assessing the relative contribution of pressure, volume, flow and respiratory rate.

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