10 episodes

Join us as we talk through clinical cases in the ICU setting, illustrating important points of diagnosis, treatment, and management of the critically ill patient, all in a casual, "talk through" verbal scenario format.

Critical Care Scenarios Critical Care Scenarios

    • Medicine
    • 5.0, 2 Ratings

Join us as we talk through clinical cases in the ICU setting, illustrating important points of diagnosis, treatment, and management of the critically ill patient, all in a casual, "talk through" verbal scenario format.

    Episode 13: Intracerebral hemorrhage and elevated ICP (part 1)

    Episode 13: Intracerebral hemorrhage and elevated ICP (part 1)

    A typical case of severe intraparenchymal hemorrhage with resulting herniation.







    Takeaway lessons







    * DOACs like apixaban (Eliquis), although not usually monitored using routine coagulation assays, tend to elevate the INR only slightly (e.g. 1.0–1.3 or so). A strikingly INR in warfarin-like ranges should raise suspicion for an additional occult cause of coagulopathy.* Manage elevated ICPs using the ENLS “tiered” approach. All neurosurgical patients should receive the tier 0 (basic management) therapies.* In the neuro-injured patient, seek “euboxia” to limit further brain injury: normal pH, normal PCO2, normal PaO2, normal BP, normal temperature etc.* Be wary relying solely upon the GCS to describe, or even to trend neurological function. A descriptive, granular survey of function (particularly motor function) is usually more useful, as well as easier to remember.















    ENLS Intracranial Hypertension and Herniation Protocol







    References







    Nestor MA, Boling B. Reversing Direct Oral Anticoagulants in Acute Intracranial Hemorrhage. Crit Care Nurse. 2019 39 (3): e1–e8.







    ICH score

    • 32 min
    Episode 12: Flight medicine with Tyler Christifulli and Sam Ireland (part 2)

    Episode 12: Flight medicine with Tyler Christifulli and Sam Ireland (part 2)

    Part two of our interfacility transfer from Hell. Tyler Christifulli, FP-C, EMT-P (@christifulli88) and Sam Ireland FP-C, EMT-P (@ireland_sam1) show us how they handle GI bleeding, arrhythmias, shock, cardiac arrest, and more, all from the confines of a helicopter. Listen to Part 1 here.







    Check out the great educational content from Tyler and Sam over at FOAMfrat, including blogs, podcasts, and online EMS continuing education.







    Takeaway lessons







    * When faced with an unstable patient in a wide complex tachycardia, stop thinking and just shock it.* As the nature of the transport (and the patient) changes, change your focus with it. The initial diagnosis is a starting point, not a headline.* Consider esmolol as an easily-titratable means of rate control in unstable patients.* Communicate ahead with the receiving hospital if urgent interventions will be needed upon your arrival.* Non-invasive positive pressure ventilation offers a preview of the hemodynamic response to intubation.

    • 43 min
    Episode 11: Flight medicine with Tyler Christifulli and Sam Ireland

    Episode 11: Flight medicine with Tyler Christifulli and Sam Ireland

    A grueling interfacility transfer gives Tyler Christifulli, FP-C, EMT-P (@christifulli88) and Sam Ireland FP-C, EMT-P (@ireland_sam1) the opportunity to show us how they handle airway management, GI bleeding, mechanical ventilation, cardiac arrest, and more, all from the confines of a helicopter.







    Check out the great educational content from Tyler and Sam over at FOAMfrat, including blogs, podcasts, and online EMS continuing education.







    Takeaway lessons







    * Prepare the best you can before departing the sending facility, while acknowledging that that time may be a factor, and that some things can’t be predicted.* The close attention by 1:1 (or more) clinicians possible during critical care transport allows some issues, such as borderline airways, to be managed by close observation rather than early intervention.* Due to the limited medications and lab studies available, particular care should be used when managing DKA. Insulin therapy should target gentle glucose correction to avoid precipitous changes in pH, osmolarity, potassium, etc.* Transport medicine, whether from the back of an ambulance, helicopter, jet, or rickshaw, is an austere environment. Personnel, equipment, and time are all limited. A thoughtful approach to logistics, prioritization, workflow, timing, and detail is at least as important as a high-level understanding of pathology.

    • 35 min
    Episode 10: Ventilator dyssynchrony

    Episode 10: Ventilator dyssynchrony

    A restless patient experiences a series of dyssynchrony events during mechanical ventilation. Come see how Bryan wades through it all, and allow us to offer an academic, yet practical approach to this sometimes-confusing subject.







    Case files







    Figure 1







    Figure 2







    Takeaway lessons







    * Start with ABCs and stabilizing the patient, then put on your thinking cap and try to optimize synchrony. It’ll reduce sedation requirements, lessen the risk of lung injury, and prevent mechanical ventilation from feeling like black magic.* Sedation is a last resort, but sometimes needed if the patient wants something (e.g. more volume) that we think is unwise.* Most dyssynchrony is the patient fighting the ventilator, so it can often be managed by allowing the patient to determine more variables within the breath. Go from volume control to pressure control, or pressure control to pressure support.* Sometimes, you won’t figure it out.* In the decompensating patient, use DOPES to remember the causes* D isplaced tube* O bstructed tube* P neumothorax* E quipment failure* S tacking of breaths* Remember “peak pressure apnea,” a phenomenon of iatrogenic hypoventilation caused by the high pressure alarm setting.







    Resources







    Flow starvation in the pressure waveform







    Premature cycling with resultant double triggering in the second breath.







    References







    * Oto B. Peak pressure apnea: An under-recognized, high-risk form of ventilator asynchrony [published online ahead of print, 2020 Feb 10]. Heart Lung. 2020;S0147-9563(20)30012-1. doi:10.1016/j.hrtlng.2020.01.012

    • 42 min
    Episode 9: Right heart failure and the SAVIOR protocol with Habib Srour (part 2)

    Episode 9: Right heart failure and the SAVIOR protocol with Habib Srour (part 2)

    The book







    Buy the new textbook (Bryan edited, Brandon authored a chapter) here or on Amazon:







    Concepts in Surgical Critical Care, First Edition







    ed. Bryan Boling, DNP, ACNP; Kevin Hatton, MD, FCCM; Tonja Hartjes, DNP, ACNP-BC, CCRN, FAANP







    The podcast







    The second piece of our in-depth look at the management of right heart failure, with a focus on preserving peri-intubation hemodynamics using the SAVIOR protocol—featuring its co-creator, anesthesiologist and intensivist from the University of Kentucky, Habib Srour. Check out part 1 here.







    Takeaway lessons







    * You don’t want to intubate patients with right heart failure, but if you do, you don’t want to do it in a hurry; a well-prepared approach will be far safer. That means doing it at the right time, not sooner and not later, and making what preparations you can before they’re needed.* Using awake intubation to gently transitioning from spontaneous breathing to mechanical ventilation via up-titration of pressure support (starting at zero) offers a gradual, reversible approach.* Sedation is often not needed for intubation. The KPET rule gives guidance if desired, but really only applies in isolation; combining drugs creates synergy in their effect and less is often needed.* 1 mg/kg ketamine* 2 mg/kg propofol* .3 mg/kg etomidate* 4 mg/kg thiopental







    Resources







    The SAVIOR algorithm. Figure 1 from Srour et al (vide infra).







    References







    * Srour H, Shy J, Klinger Z, Kolodziej A, Hatton KW. Airway Management and Positive Pressure Ventilation in Severe Right Ventricular Failure: SAVIOR Algorithm. J Cardiothorac Vasc Anesth. 2020;34(1):305‐306. doi:10.1053/j.jvca.2019.05.046

    • 31 min
    Episode 9: Right heart failure and the SAVIOR protocol with Habib Srour (part 1)

    Episode 9: Right heart failure and the SAVIOR protocol with Habib Srour (part 1)

    The book







    Buy the new textbook (Bryan edited, Brandon authored a chapter) here or on Amazon:







    Concepts in Surgical Critical Care, First Edition







    ed. Bryan Boling, DNP, ACNP; Kevin Hatton, MD, FCCM; Tonja Hartjes, DNP, ACNP-BC, CCRN, FAANP







    The podcast







    An in-depth look at the management of right heart failure, with a focus on preserving peri-intubation hemodynamics using the SAVIOR protocol—featuring its co-creator, anesthesiologist and intensivist from the University of Kentucky, Habib Srour.







    Takeaway lessons







    * When facing undifferentiated shock and a complex picture, look for one point of data to help distinguish the etiology. Try touching the feet: cold is a good indicator of a significant cardiogenic component.* The flip side of hypoxic vasoconstriction is hyperoxic vasodilation of the pulmonary vasculature—i.e. an overly high FiO2 will tend to worsen V/Q matching.* To hemodynamically manage RV failure without worsening RV afterload, consider the Rule of 8s cocktail:* Epinephrine .08 mcg/kg/min* Dopamine 8 mcg/kg/min* Vasopressin .08 units/min* Inhaled epoprostenol (Veletri/Flolan) 8 ml/hr* The “lung pump” of negative pressure respiration provides a substantial amount of cardiac output, particularly in the setting of RV failure. Paralysis, sedation, and intubation removes this. The period of apnea also worsens acidosis which increases PVR.* The dead space to tidal volume ratio increases by at least 50% after intubation; it will be impossible to match an already-high spontaneous minute ventilation on the ventilator.







    Resources







    The SAVIOR algorithm. Figure 1 from Srour et al (vide infra).







    References







    * Srour H, Shy J, Klinger Z, Kolodziej A, Hatton KW. Airway Management and Positive Pressure Ventilation in Severe Right Ventricular Failure: SAVIOR Algorithm. J Cardiothorac Vasc Anesth. 2020;34(1):305‐306. doi:10.1053/j.jvca.2019.05.046

    • 31 min

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