Critical Care

POLST Discordant Care

You are working at a community trauma center when an elderly male is brought to the ED after being struck by a car.  The patient is complaining of right sided chest pain and is in respiratory distress. He has a patent airway, is breathing spontaneously and is normotensive.  He is confused and not oriented to place or time. A chest x-ray does not reveal a pneumothorax, but does reveal 5 contiguous rib fractures. The patient is likely to require intubation due to the increased work of breathing.  You review the patient's chart and note that he has a POLST on file indicating a DNR/DNI status as well as identifying his daughter as a medical power of attorney who may override the POLST. A nurse lets you know the patient’s family has arrived.  You wonder how the presence of the POLST form will influence your conversation with the family.

Venous thrombosis after VV ECMO: What is the true prevalence?


Venous thromboembolism is considered one of the most preventable causes of in-hospital death. Venovenous extracorporeal membrane oxygenation (VV ECMO) utilization for severe respiratory failure has increased in the decade following the 2009 influenza A H1N1 pandemic and the publication of the CESAR trial.1 The interaction between a patient’s blood and the ECMO circuit produces an inflammatory response that can provoke both thrombotic and bleeding complications. In a systematic review of patients with H1N1 treated with VV ECMO published in 2013, the incidence of cannula-associated deep venous thrombosis (CaDVT) was estimated to be as low as 10 percent; however, more recent data suggests the incidence of venous thrombosis after decannulation is much higher. Additionally, a significant proportion of CaDVT are distal thrombi located in the vena cava, which would be missed with a traditional ultrasound diagnostic approach after decannulation from VV ECMO.  

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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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