Critical Care Scenarios

Brandon Oto, PA-C, FCCM and Bryan Boling, DNP, ACNP, FCCM
  • 4.5 (238)
  • MEDICINE
  • UPDATED BIWEEKLY
Critical Care Scenarios

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.

  1. 6D AGO

    Academy bites: The power of disagreeing

    Learn more at the Intensive Care Academy! Find us on Patreon here! Buy your merch here!

    9 min

  2. APR 16

    Episode 86: EEGs in the ICU with Carolina Maciel

    We discuss the basics of EEG in the ICU, including when to do it, selecting the appropriate study, and the basics of bedside interpretation, with Carolina B Maciel, MD, MSCR, FAAN, triple boarded in neurology, neurocritical care, and critical care EEG. Learn more at the Intensive Care Academy! Find us on Patreon here! Buy your merch here! Takeaway lessons * There is little to no role for a very short (12 hours. 2-12 is a middle ground (both clinically and for billing purposes). In most ICU cases, a “middle” study of a few hours can be done, then the findings used to inform the need for a longer study; validated scores exist for this, such as 2HELPS2B. * Don’t forget the non-seizure diagnoses that can be made/supported from EEG, such as brain death, cefepime-induced encephalopathy, sudden clinical changes due to osmotic shifts, etc. In reality, EEG readers, particularly in the community, may or may not be making great efforts to appreciate these things. You will get better reads if you communicate your questions to the reader, and consulting neurologists/neurointensivists may be able to glean more from a non-specific EEG report as well. Critical care EEG folks like Carolina may be the most helpful, but there are very few training programs for this. * Basic filters on the EEG include the high and low pass filters (should be LFF of 1 hz, HFF ~7–8 hz), and potentially a notch filter for 60 hz (in the US) or 50 hz (in Europe) to filter out AC electrical noise. * Dark vertical lines on the strip occur every 1 second. With normal scale there should be about 3 centimeters (around your thumb’s length) between them. * Odd numbered leads are on the left side of the head. Even numbers are on the right. Z-numbered leads are in the sagittal midline. * Do you see intermittent bursts of something pointy, like it will hurt to sit on? These may be muscular artifact, which can be hard to distinguish (look at the patient to see if they’re moving/twitching), but if not, this may be an epileptic discharge; similar to a PVC, or someone coughing in the symphony audience, it’s an inappropriate interruption in brain activity. This may be focal or global (all leads), and focal may be higher risk. They may be repetitive, occurring somewhat regular intervals, which are also more concerning. Ultimately, the concern is always whether they are going to evolve/organize into full seizures, so if no evolution ever occurs, that is also more reassuring. * When to treat epileptogenic discharges on EEG is always a judgment call and must be put in context of the patient. More abundant discharges with a more malignant appearance are more concerning, but the clinical correlation matters too; EEG findings with no clinical correlate are less worrisome. Convulsive seizures are a medical emergency (especially with continuous tonicity), but non-convulsive electrical activity, even non-convulsive status, usually has room and time to weigh the risks versus the benefits of therapy. Talk to experts and make a thoughtful decision. * Carolina hates fosphenytoin due to the cardiotoxi...

  3. APR 2

    Lightning rounds 51: Hemodynamic interfaces with Philippe Rola

    Philippe Rola, intensivist, master of the VEXUS scan, and founder of the Hospitalist and Resuscitationist conference, shares his recent model of four hemodynamic interfaces to describe the entire circulatory system. Register for the H&R conference (May 22-23 2025) here with the discount code provided in the show. (No, we’re not sponsored, just a cool event.) Learn more at the Intensive Care Academy! Find us on Patreon here! Buy your merch here!

    44 min

  4. MAR 19

    Episode 88: ICU Liberation SCCM Congress 2025

    A roundup from members of the SCCM’s ICU Liberation committee, recorded at SCCM Congress 2025. Included: * Heidi Engel * Kali Dayton * Kristina Betters * Stacey Williams * Jessica Anderson * Jenna Domann * Sergio Zanotti * Erika Setliff * Brian Peach

    14 min

  5. MAR 5

    Lightning rounds 50: Mastering PA catheter placement with Matt Siuba

    We learn the vanishing art of placing the PA (Swan-Ganz) catheter, with intensivist and friend of the podcast Matt Siuba (@msiuba). Learn more at the Intensive Care Academy! Find us on Patreon here! Buy your merch here! Takeaway points * Good sheath placement: ensure your skin nick is in the same hole as your dilator; use patient, steady pressure, especially as the “shoulder” (where the dilator meets the sheath) reaches the skin; insert the dilator completely into the sheath so you can see if it shifts, and dilate using both hands (one near the tip, one at the back holding the sheath and wire). * The right IJ is best (try to leave this open when placing non-positional lines like a triple lumen), left subclavian next best, third choice left IJ or right subclavian. Femoral placement is very tough without fluoroscopy; it requires two turns (into the RV, then out into the PA) and can be challenging to escape the RV. A brachial vein in the arm can occasionally be used as well. * Floating out of the left IJ is often obstructed by bumping into the innominate-SVC junction. Instilling just 0.5-1 cc of air in the balloon is often enough to float around this turn. This occurs less from the left subclavian or brachials, but if it does occur, the same maneuver may help. * Remember to place the contamination sleeve (Swandom) before inserting the Swan! Once you’re in, it’s too late; you’ll need to remove it and refloat. You don’t need to seal it, just get it around the catheter. * Flush each lumen before inserting and cap each one, except the distal/PA port. Connect that to your transducer and flick it to test transduction. Check the balloon; rarely, but sometimes, they will fail. Remember to always inflate the balloon using the included volume-limited syringe, and allow it to passively deflate from its elasticity. * If a balloon does not self-deflate, replace the catheter; the balloon is not reliable. * Once you reach 15 cm, inflate the balloon. By 15-20 cm, you should be in the RA; measure your RA pressure (overall mean is fine for ICU purposes). If the waveform is not distinct with clear components, flush the catheter; it may be damped by clots. * Tricuspid pathology (TR, stenosis) can make a Swan challenging, but not as often as people think. And the harder the Swan, often, the more important the data. * If you reach 30 cm without an RV tracing (except in some very large or very end-stage PH patients), you have probably gone astray, either coiled in the RA or gone through to the IVC. * Once in the RA, make a quarter rotation counter-clockwise (assuming you started with the tip curved medially). This will help orient the tip towards the tricuspid valve. If it’s not getting through, drop the balloon, come back to 20, readvance, repeat as needed. * If still not going, sometimes the tip has looped back into the RA while the middle of the catheter has “elbowed” through the tricuspid into the RV. If this happened, retract the catheter, and the tip may flop through as you come back. You’ll know this as the RV waveform will appear during retraction; inflate the balloon then and drive forward fast. * If you can’t get through a regurgitant valve, a faster/more aggressive advancement through the tricuspid valve may help. You need to launch through before it kicks you out.

    1h 4m

  6. FEB 19

    Lightning rounds 49: The Vortex approach with Nicholas Chrimes

    We learn about the Vortex approach to airway management, as well as airway algorithms and mental models in general, with Vortex creator and anesthesiologist Dr. Nicholas Chrimes, anaesthetist and cofounder of the Safe Airway Society. Learn more at the Intensive Care Academy! Find us on Patreon here! Buy your merch here! References * The Vortex website

    1h 7m

  7. FEB 5

    Episode 85: Tracheostomy basics with Vinciya Pandian

    We discuss the basics of evaluation for tracheostomy placement, periprocedural care, and post-procedure complications with Vinciya Pandian, PhD, ACNP, FCCM, tracheostomy nurse practitioner and researcher. Learn more at the Intensive Care Academy! Find us on Patreon here! Buy your merch here!

    46 min

  8. JAN 29

    Academy bites: You were here when we were not

    Learn more at the Intensive Care Academy! Find us on Patreon here! Buy your merch here!

    16 min
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    About

    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.

    Information

    • Creator
      Brandon Oto, PA-C, FCCM and Bryan Boling, DNP, ACNP, FCCM
    • Years Active
      2019 - 2025
    • Episodes
      203
    • Rating
      Clean
    • Show Website
      Critical Care Scenarios

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