Critical Care

Hemodynamic support in Acute Right Heart Failure due to Pulmonary Embolism

A 68 year old male with a history of a right ankle ORIF three weeks ago is transferred to your ICU for management of a pulmonary embolism. He developed acute dyspnea while at physical therapy and was taken to an ED where he was found to have bilateral pulmonary emboli extending into both segmental and subsegmental pulmonary arteries on CTPE. His workup included elevated troponins and an echocardiogram that showed a dilated RV with hypokinesis of the RV free wall and reduced tricuspid valve annular systolic excursion. He was started on a heparin infusion prior to transport and was hemodynamically stable when you took the transfer call. When he arrived to your facility he was mentating well but his BP was 85/50 with a HR of 115 and an spO2 of 96% on 2L NC. How will you address his hypotension?

A Novel Coronavirus (2019-nCoV)

While most coronaviruses cause mild respiratory illness consistent with the common cold, two lethal coronaviruses have been previously identified, including the acute respiratory syndrome coronavirus (SARS-CoV) in 2002 demonstrating 10% mortality and the Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012 producing 37% mortality. In December 2019, a novel coronavirus (2019-nCoV) was isolated from a cluster of patients with pneumonia in Wuhan, China. As reported in the Lancet last week, two thirds of the affected patients in a case series had a history of exposure to the Huanan seafood market.

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Back to Basics: Recurrent Polymorphic VT/Torsades de Pointes

It's pretty easy to remember what to do with unstable polymorphic VT/Torsades de Pointes (shock 'em!), but what are your options with recurrent stable episodes?  

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Slippery Platelets and Slip & Falls

You are assessing a 68 year old male who fell down three steps and struck his head on the ground.  His history is significant for a drug eluting stent placed after a cardiac catheterization two months ago.  As a result he is on dual antiplatelet therapy. You wonder what the impact of aspirin and clopidogrel is on the risk of intracranial hemorrhage (ICH).

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Preventing ventilator-induce lung injury (VILI): Optimizing PEEP titration in ARDS

Lung-protective mechanical ventilation with low tidal volume and restricted plateau pressure improves survival in ARDS. However, the optimal approach to PEEP titration to minimize VILI is still debated. Should oxygenation, lung compliance, driving pressure or transpulmonary pressure guide adjustment of PEEP in ARDS?

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Severe hyperthermia? Its in the bag.

While your friends at home are shivering in the Camden, NJ winter, you are on an elective retrieval medicine rotation in New South Wales, Australia.  A 32 year old patient arrives in a rural emergency department obtunded. His friends state he was out hiking and may have used some cocaine as well. His initial vital signs are notable for hypotension and a core temperature of 41.5C (106.7F).  There are no fans available for evaporative cooling and no gel adhesive body temperature controlling devices (such as those used following cadiac arrest). The patient requires intubation which is done uneventfully, the staff asks what tools you might use to rapidly reduce the body temperature.

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What harm could a vitamin cause?

EMS brings in a 45 year old male with a PMHX of tobacco abuse who was rescued in a house fire.  The report is that a cigarette dropped on the patient’s couch while he was sleeping and caused a smouldering fire.  It resulted in a significant amount of smoke creation but very little fire damage in the house. The patient has no visible burns.  On arrival, the patient’s pulse oximetry on room air is 84%. He is alert and oriented but notes a sense of persistent dyspnea. His workup is significant for a lactate of 2.2 but otherwise benign.  Co-oximetry is normal without evidence of severe carbon monoxide poisoning. The patient does not display evidence of inhalational burns. The patient’s new hypoxia and dyspnea is worrisome so you planned admission to the hospital but wonder if you should give hydroxycobalamin empirically in case of occult cyanide toxicity.

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COuld this patient have a PE?

As you scan the ED trackboard, you recognize the name of a 22 year old patient who you saw the week before after a house fire.  At that time, the patient was treated for carbon monoxide (CO) poisoning and briefly admitted to the hospital. Today’s chief complaint is dyspnea and chest pain.  You note that the patient is tachycardic, hypoxic, and complained of pleuritic chest pain at triage. You wonder if the prior exposure to carbon monoxide should raise your pre-test probability for certain diagnoses.

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