Critical Care

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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Corticosteroids in ARDS

Several drugs have been investigated in patients with ARDS, including epoprostenol, nitric oxide, statins, and methylprednisolone, but have not improved survival. Meduri et al. performed an RCT demonstrating that methylprednisolone was associated with a reduction in lung injury score and duration of mechanical ventilation. While not powered to evaluate mortality, this trial raised interest in the use of corticosteroid to mitigate inflammatory lung injury. The 2017 Guidelines from the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) recommend steroids for treatment of ARDS based on a meta-analysis of nine randomized controlled trials demonstrating reduction in markers of inflammation and duration of mechanical ventilation, although many of the trials had a small sample size and some were performed without lung protective ventilation. In March 2020, Villar et al. published the largest randomized control trial of corticosteroid therapy for moderate to severe ARDS investigating the impact of dexamethasone on survival and duration of mechanical ventilation.  

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The Furosemide Stress Test

You admitted a 72 year old male to the ICU for septic shock from community acquired pneumonia. He required intubation and mechanical ventilation for failure to improve oxygenation with NIPPV and encephalopathy. He received broad spectrum antibiotics and a 30 cc/kg crystalloid bolus. His MAP was persistently in the 50s despite adequate fluid resuscitation and based on your exam he does not appear hypovolemic. Norepinephrine is started and despite adequate MAP he is oliguric. His only medical history is he was a previous smoker with COPD, HTN, HLD but normal renal function with a Cr of 0.8 two months prior. His Cr on admission is 2.2 and a foley is placed and his UA shows granular casts. He is not acidotic and his electrolytes are normal. 

You are concerned this patient is heading towards renal replacement therapy. He is adequately fluid resuscitated and has a MAP above 65 on a vasopressor but is still not making urine and has signs of ATN on urinalysis. Renal replacement therapy is an invasive procedure and has associated risks. If a patient has a chance to have renal recovery with a more conservative approach then this should be considered.  You wonder if there is a diagnostic test which can be used to assess the potential for renal recovery.

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Prone positioning in pregnant patients with ARDS due to COVID-19: Yes or no?

A 34-year-old woman at 32 weeks gestation presents to the emergency department with cough, dyspnea and hypoxemia. She rapidly progresses to severe ARDS despite lung protective ventilation, paralysis and inhaled epoprostenol. P/F ratio is 99 mm Hg. Is prone positioning safe to perform in pregnant patients with severe ARDS? If so, are modifications necessary to offload the abdomen and monitor the fetus? A recently published review in Obstetrics and Gynecology discusses this important topic. 

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