Archive for category Critical Care

Acid Base: Part I

I have spoken about it for a while, but I’ve finally gotten it done: the acid-base podcast. The podcast is going to be in 3 or 4 parts. They are segmented from a lecture I gave to my residents recently.

This lecture discusses a quantitative approach to acid base management. This is also known  as the Fencl-Stewart approach, the strong-ion approach or the physicochemical approach. It provides explanations for why acid base disorders occur in human pathophysiology. The classic method used in the USA is the Henderson-Hasselbalch (misspelled on my slides) approach. I find this method to provide no comprehensive explanation for why things are as they are. Through the quantitative approach, you can also understand the H&H approach and continue to use it with new insight.

[Click here to read more and watch the vodcast]

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Placing the Intubating Laryngeal Airway

My favorite supraglottic airway is the Cookgas Air-Q; it was created by an anesthesiologist, Dr. Daniel Cook (As always, I have no conflicts of interest). He just created a new device that allows the placement of an esophageal blocker through the laryngeal airway. I gave him a call to hear about the new product and in the course of that conversation, he gave me a ton of tips on the placement of laryngeal airways in general. Sorry about the audio quality, his cell phone was probably AT&T : ).

[Click Here to Read More and to Hear the Episode]

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A phD in ECG with Dr. Steven Smith

Electrocardiograms can be subtle; but you can’t miss them or patients die. Today, I got to interview Dr. Steven Smith. Dr. Smith is faculty at the Hennepin Program and author of one of the best books on EKGs in the ED, The ECG in Acute MI.

Dr. Smith’s EKG Blog is probably the best free EKG site out there for Emergency Physicians and Intensivists.

We cover a ton of stuff including the most subtle form of MI, why inferior depressions don’t mean inferior ischemia, and when a BOATload of calcium is a really good idea.

[Click here to read more and to Hear the Podcast]

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Interview with EMS Physician, Cliff Reid

I was able to cajole Cliff Reid of the amazing blog, on to the EMCrit program. Cliff is truly a doc after my own heart as you will hear from the cast.

He is currently an EMS physician and Director of Training at the New South Wales Ambulance Service.

Cliff’s blog, is an incredible collection of timely articles on emergency medicine, ems, critical care and resuscitation.

Cliff and I discuss prehospital intubations, helicopters for EMS, and upstairs care, outside the walls of the hospital.

[Click here to read more and hear the podcast]

photo by mad scientist

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Delayed Sequence Intubation (DSI)

The Case

You have a 50 y/o male with bad bilateral pneumonia. BP 108/70, HR 96, RR 28. He is delirious, agitated, and looks sick, sick, sick! Saturation is 70% on a nasal cannula; when you try to place the patient on a non-rebreather (NRB) he just swats your hand away and rips off the mask. It is obvious to everyone in the room that this patient needs intubation, but the question is how are you going to do it?

Your first impulse may be to perform RSI, maybe with some bagging during the paralysis period. This is essentially a gamble. If you have first pass success, you (and your patient) may just luck out, allowing you to get the tube in and start ventilation before critical desaturation and the resultant hemodynamic instability. However, the odds are against you: bagging during RSI predisposes to aspiration, conventional BVM without a PEEP valve is unlikely to raise the saturation in this shunted patient, and if there is any difficulty in first-pass tube placement your patient will be in a very bad place.

Is There a Better Way???

[Read and Listen to the DSI Podcast]

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Ummm… He’s tasty, but he needs some salt

In EMCrit Podcast 39, I try to decipher the management of hyponatremia in the ED. After reading countless articles from the nephrology literature…I can still attest that I have not a friggin’ clue about renal physiology. But I think I have found a simpler path to the work-up and treatment of low sodium in the ED.

[Click here to read more and to hear the podcast]

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The ED Critical Care Dirty Dozen for 2010

Here are my 12 favorite ED Critical Care things for 2010…the EMCrit Dirty Dozen:

12. SmartEM by David Newman and Ashley Shreves

11. The Poison Review by Leon Gussow

10. Academic Life in Emergency Medicine by Michelle Lin

9. Zdoggmd–the funniest internist I have ever come across

8. Emergency Medicine Cases Podcast by Anton Hellman

7. One Night in the ED, an incredible radiology blog for EM folks by a radiologist, Daniel Cornfeld

6. Steve Smith’s EKG Blog-even the cardiologists are not giving the same amount of detail as you will find here

5. by Cliff Reid

4. EM:RAP by med ed hero, Mel Herbert

3. Ercast by my friend, Rob Orman

2. the Life in the Fast Lane Blog headed up by the amazing Mike Cadogan and Chris Nickson

1. Well for #1, you are just going to have to listen

[Click here to hear the Show]

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When an ED starts providing advanced care for severe sepsis, lactate testing is an absolute requirement. Lactate use brings up a lot of questions, especially if it is not commonly ordered in your department. In this podcast, I discuss all of the lactate questions that have come up in the course of the NYC Sepsis Collaborative.

[Click Here to Read More and to Hear the Podcast]

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Management of Traumatic Arrest

This week I am discussing the management of traumatic arrest. A whole host of things need to happen in rapid succession, but two things you definitely should not be doing are closed-chest CPR or giving ACLS medications. We discuss who gets a thoracotomy, what to do if a thoracotomy is not indicated, and when to stop.

[Click Here to Read More and to Hear the Podcast]

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Extubation in the Emergency Department

If you can put an ET tube in, I think you should be able to remove it as well. In this podcast, I discuss extubating patients in the ED. Specifically, I deal with patients who have only been intubated for a few hours in distinction to extubation of the patient who has been lingering in your ED for 2-3 days. The best patients for this short-term extubation are those intox folks with a low GCS and signs of trauma, overdoses, or endoscopy cases.

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