Critical Care

Tracheostomy decannulation: To cap or not to cap?

A 49-year-old woman was intubated for acute hypoxemic respiratory failure secondary to pneumonia, which was complicated by empyema. She failed extubation and ultimately required tracheostomy for prolonged mechanical ventilation. After transfer to the intermediate care unit, she was successfully weaned from the ventilator for over 24 hours. She tolerated prolonged deflation of her tracheostomy cuff and swallowed water without aspiration. She underwent a tracheostomy tube occlusion test and there was no obstruction to air flow with a size 7 fenestrated tracheostomy tube in place. She is requiring suctioning once every 12 hours. You are assessing her readiness for tracheostomy decannulation and are considering the utility of a capping trial.    

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Another take on balanced crystalloids vs. saline

It’s a familiar call ahead to the ED - an adult patient who is febrile, hypotensive, with suspicion towards infection.  While setting up the room, the patient’s bedside nursing team asks if you’d like them to get saline or lactated Ringer’s (LR) ready for resuscitation.  You wonder if there’s any new evidence examining the use of saline versus balanced crystalloids in the emergency department.

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Critical Cases - Bradycardia Emergency!

An 87 yo male is brought in by EMS after a syncopal event while on the toilet, resulting in a fall and head injury. EMS reports a heart rate in the 30s en route. As your approach the resuscitation bay you begin to think about the causes of bradycardia and what your approach will be to stabilize this potentially very sick patient....

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Hypercalcemic crisis

A 52-year-old woman with a history of hypertension sustained a large left frontoparietal intracerebral hemorrhage resulting in right-sided flaccid paralysis complicated by acute respiratory failure status post tracheostomy for prolonged mechanical ventilation. She is transferred to the step-down intensive care unit for ventilator weaning. Serum calcium level returns elevated at 11.3 mg/dL with a serum albumin level of 2.8 g/dL. What is the most likely cause of her hypercalcemia and how should it be managed?

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Pressors and Fluids - Not either/or but both/and

It's a typical day in the ED.  You are asked to see your next patient who is a 60 year old male, recently discharged from the hospital after being treated for cellulitis presenting with abdominal pain and diarrhea.  He’s tachycardic and hypotensive to 75/40.  The patient is mentating well.  After taking a more thorough history your differential diagnosis narrows in on intra-abdominal sepsis associated with significant volume losses.  The lactate returns at 6.  On volume assessment by physical exam and POCUS, the patient is significantly volume down.  You know that getting the antibiotics and fluids on board is the cornerstone of treatment, but they will take some time to be given.  You wonder if you should temporize your resuscitation with pressors during the time it takes for the fluids and antibiotics to be administered.

VA-ECMO for massive pulmonary embolism

A 60-year-old man presents to the ED after an episode of syncope. He is initially hemodynamically stable and undergoes CT demonstrating saddle pulmonary embolism. He returns from radiology with tachycardia and hypotension refractory to fluids and requiring vasopressor support. Bedside echo reveals RV dilation and severely reduced RV systolic dysfunction with septal flattening consistent with RV pressure overload. As you start systemic anticoagulation with heparin, you consider the indications for thrombolysis, surgical embolectomy and VA-ECMO.   

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Crucial Conversations in the ED

EMS calls ahead with reports of an adult patient in respiratory distress.  They are concerned the patient will need to be intubated on arrival.  Recognizing the name, you pull up a previous chart and review the patient’s history.  You realize this is their 10th presentation this year and on reviewing their most recent oncology note you note their oncologist has recommended they consider hospice due to end stage malignancy without further treatment options.  The patient arrives, is in distress, and does not have capacity but can be temporized by NIPPV while decision making occurs.  Their power of attorney comes to the hospital soon after but states they never got around to establishing an advanced directive. How should you approach this conversation?

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Critical Cases - Heat Emergency!

EMS brings in a patient who was found down in his front lawn. They report he is dry and very hot to the touch, and has been unresponsive during transport. As you approach the resuscitation bay you quickly run down potential causes of a heat emergency and begin to think about the best way to treat this patient.....

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