431 episodes

Help me fill in the blanks of the practice of ED Critical Care. In this podcast, we discuss all things related to the crashing, critically ill patient in the Emergency Department. Find the show notes at emcrit.org.

EMCrit Podcast - Critical Care and Resuscitatio‪n‬ Scott D. Weingart, MD FCCM

    • Medicine
    • 5.0 • 1 Rating

Help me fill in the blanks of the practice of ED Critical Care. In this podcast, we discuss all things related to the crashing, critically ill patient in the Emergency Department. Find the show notes at emcrit.org.

    EMCrit 293 – The Jerk & Check, Functional Heuristics in Resuscitation Project (MotR)

    EMCrit 293 – The Jerk & Check, Functional Heuristics in Resuscitation Project (MotR)

    What is a Heuristic?

    A short cut to extended, analytical thinking that when functional provides a solution that may not be optimal but will be sufficient. When based on cognitive biases, heuristics may be dysfunctional. Wikipedia has a fairly good discussion of heuristics.

    Thinking Fast and Slow





    System 1 vs. System 2



    Our interview with Gary Klein

    ERADs are the Action Version of Functional Heuristics

    Emergency Reflex Action Drills from Lauria

    Jerk & Check

    Never immediately act on a heuristic. Have your kneejerk response and then use System 2 to Check

    Functional Heuristics in Resuscitation

    Flank Pain in Elderly is AAA until the Ultrasound

     

    Severe Bradycardia/Heart Block = Hyperkalemia until you see the K

     

    Slovis' Hypokalemia = Hypomagnesemia (Hypok=HypoMAG)

     

    Unexplained Hypotension gets antibiotics

     

    Hypotension and Abdominal Pain in Child-Bearing Age Female is Ectopic

     

    Chest Pain Plus

     

    Tamponade is dissection until it is not

     

    Old stay, young go

    Err towards Young D/C and Old Stay and then check

    Think LP/do LP

     

    The diagnoses of costochondritis and gastroenteritis do not exist

     

    What is going to kill this patient? (Pre-Mortem)

    a adaption of Gary Klein's idea

    Ad Spot: Butterfly IQ+

    Read about and watch Mike Stone demonstrate BiPlane



    EMCrit listeners get a free case worth $99 with the purchase of a Butterfly iQ+ probe and membership. Simply use the referral code "EMCRIT" at checkout

    Note: Butterfly provided a probe for testing to Metasin LLC

    Now on to the Podcast...

    • 18 min
    EMCrit 292 – IV T3 for Myxedema Coma, A Different Take with Eve Bloomgarden

    EMCrit 292 – IV T3 for Myxedema Coma, A Different Take with Eve Bloomgarden

    So we recently did a Myxedema Episode with Arti Bhan. On the show, we were supposed to have a 2nd endocrinologist, but due to scheduling issues, it didn't work out. For a different take on IV T3, today we have that endocrinologist on the show.



    Eve Bloomgarden, MD

    Dr. Eve Bloomgarden, MD is an endocrinologist at Northwestern Memorial Hospital and an assistant professor in the Division of Endocrinology, Metabolism and Molecular Medicine at Northwestern University Feinberg School of Medicine. Dr. Bloomgarden received her medical degree from New York University and completed residency and fellowship training at the Hospital of the University of Pennsylvania. Dr. Bloomgarden’s clinical expertise is in the diagnosis and management of thyroid disorders and thyroid cancer as well as general endocrinology. She is a clinician educator and contributes to the medical education of students, residents, and fellows. She loves spending time with her husband, also a physician, and their two young children. The COVID crisis has brought out her social media voice and her strength as an advocate for her fellow healthcare workers.

    If the Patient Looks Crappy...

    This is when to consider combined therapy in Dr. Bloomgarden's practice

    Always Give Steroids First

    I think this is even more critical if you are using LT3

    Combined LT4/LT3 Dosing Strategy

    LT4 200-300 mcg



    &



    LT3 5-10 mcg IV then 2.5-5 mcg q8 hrs (until pt stabilizes and then switch to just LT4)

    American Thyroid Association Guidelines



    * Guidelines from American Thyroid Assoc.



    21c. In patients with myxedema coma being treated with levothyroxine, should liothyronine therapy also be initiated?





    ■  Recommendation

    Given the possibility that thyroxine conversion to triiodothyronine may be decreased in patients with myxedema coma, intravenous liothyronine may be given in addition to levothyroxine. High doses should be avoided given the association of high serum triiodothyronine during treatment with mortality. A loading dose of 5–20 μg can be given, followed by a maintenance dose of 2.5–10 μg every 8 hours, with lower doses chosen for smaller or older patients and those with a history of coronary artery disease or arrhythmia. Therapy can continue until the patient is clearly recovering (e.g., until the patient regains consciousness and clinical parameters have improved).

    Weak recommendation. Low-quality evidence.



    Not Many Patients Treated with LT3 in this Review

    Japanese Review of Treatment Options for Myxedema

    Want More Eve?



    * Check her out on the Curbsiders



    More Myxedema and Thyroid on EMCrit



    * IBCC chapter & cast - Myxedema coma (decompensated hypothyroidism)

    * Decompensated Hypothyroidism ("Myxedema Coma")(Opens in a new browser tab)

    * Thyroid Storm(Opens in a new browser tab)

    * Podcast 149 – Thyroid Storm

    • 11 min
    EMCrit 291 – For Frak’s Sake, Ketamine is at least as Hemodynamically Stable as Etomidate!

    EMCrit 291 – For Frak’s Sake, Ketamine is at least as Hemodynamically Stable as Etomidate!

    Terren Trott, MD

    Emergency Medicine + Ultrasound + Critical Care Physician + Airway Enthusiast. Editor for 5minuteairway and critical care now.







    The Original Crit Care Now Blog Post



    Terren's Post on Critical Care Now



    The Two NEAR Database Papers on Ketamine Hemodynamics



    * Mohr et al.

    * April et al.



    Jabre RCT on Ketamine vs. Etomidate



    * KetaSED - Jabre Lancet RCT

    * Bottom Line KetaSED Summary

    * Reanalysis of Jabre demonstrating that all intubations were done by EM in ED or EMS Environment



     

    Now on to the Podcast...

     

    • 26 min
    EMCrit 290 – Decompensated Hypothyroidism and Myxedema with Dr. Arti Bhan

    EMCrit 290 – Decompensated Hypothyroidism and Myxedema with Dr. Arti Bhan

    Thyroid storm is tumultuous and exciting; Myxedema is somewhat enervating and markedly less exciting--but it is also life threatening. We need to know about this disease! Today, I interview Arti Bhan, MD on the topic:

    Arti Bhan, MD

    Division Head, Endocrinology @HenryFord Health System



    "I strive to provide the highest quality health care services to all my patients efficiently, effectively and compassionately. I believe in partnering with my patient in order to achieve our goals."



    Dr. Bhan received her medical degree from India. She completed an Internal Medicine Residency at St. John Hospital and Medical Center and then went on to a fellowship in Endocrinology at Henry Ford Health System.



    She has been a senior staff physician at Henry Ford since 2003 and is currently serving as the Division Head of Endocrinology. She is active in clinical research and is an investigator in numerous trials, including NIH funded studies. She is published in peer reviewed literature and is the Associate Editor for Clinical Diabetes.



    Dr. Bhan's main area of interest is in thyroid disorders, and she trains fellows in thyroid ultrasonography and thyroid biopsies.

    What We Cover on Myxedema



    * What is the look of myxedema

    * What TSH should get you worried

    * How to treat Myxedema

    * Should we use T3 (LT3)

    * What do resus docs screw up when treating myxedema



    Related & More



    * IBCC Myxedema

    * EMCrit Thyroid Storm



    Now on to the Podcast...

     

    • 17 min
    EMCrit 289 – Ketamine Only Intubation Paper with Brian Driver

    EMCrit 289 – Ketamine Only Intubation Paper with Brian Driver

    Brian Driver, MD

    Dr. Brian Driver is the Director of Clinical Research in the Department of Emergency Medicine at Hennepin County Medical and an Assistant​ ​Professor​ ​of​ ​Emergency​ ​Medicine at the University of Minnesota Medical School. In 2016, his research was selected for Airway World’s Airway Article of the Year.



    Dr. Driver loves teaching, as it keeps his knowledge and skill-set fresh, and challenges him to think in new ways. He sees it as a good way to learn something new every day. His favorite moments are with students who are particularly curious, and eager to solve new problems. “It’s fun to work with them and break it down, and work through their knowledge gaps and figure out the best way to approach new scenarios.”



    In his free time, Dr. Driver likes to mountain bike, run, and during some parts of the year, can be found biking over a frozen lake on the way to work.

    The Two NEAR Database Papers on Ketamine Hemodynamics



    * Mohr et al.

    * April et al.



    A Flawed Analysis of the Papers



    EMCrit Podcast on the topic

    The Driver Ketamine Paper



    * Driver Ketamine Only



    My Podcast on Ketamine Dissociated Intubation

     

    Now on to the Podcast...

    • 20 min
    EMCrit 288 – Neurogenic Shock & Should we be Using Vasopressors for Hemorrhagic Shock?

    EMCrit 288 – Neurogenic Shock & Should we be Using Vasopressors for Hemorrhagic Shock?

    Neurogenic Shock

    Neurogenic shock is on our differential for hypotension and hemodynamic instability in trauma patients. Today, we discuss this condition as well as the use of vasopressors for hemorrhagic shock.

    Neurogenic Shock is not Spinal Shock

    Spinal Shock is a loss of reflexes below the level of the injury

    What Level?

    Preganglionic sympathetic neurons originating in the hypothalamus, pons and medulla are located in the intermediolateral cell column of the spinal cord between the first thoracic (T1) and second lumbar (L2) vertebrae. Theoretically, any SCI within or above this could cause sympathetic disruption. Since sympathetic innervation of the heart only occurs from T1 to T5, it is often said that neurogenic shock can only occur when the lesion is above the mid-thoracic (T6) level. [ 27697845]

    Presentation



    * Doesn't necessarily happen instantly

    * Won't always have bradycardia

    * Move arms and legs during primary survey



    Fluids

    InoPressors



    * dopamine is bad--diuresis



    MAP Push



    * 85 for 7 days???

    * UPDATE: Recently published cohort trial supports this practice (but not great evidence here) [Journal of Trauma and Acute Care Surgery Issue: Volume 90(1), January 2021, p 97-106]



    More Reading



    * Deb Stein's ENLS on Spinal Cord Injury

    * Descriptive Reporting of Neurogenic Shock



    Should we be using Vasopressors in Hemorrhagic Shock?

    I listened to a thought-provoking episode of Traumacast today. It was an interview with Dr. Carrie Sims on the use of Vasopressin after Hemorrhagic Shock.



    The contention is that Vasopressin at the 0.03-0.04 unit/minute dose will not affect blood pressure unless the patient is actually vasopressin deficient.



    5th-10th Unit of blood, vasopressin levels begin to drop



    Are we diluting out our stress hormones?



    RCT by Carrie Sims et al. (PMID: 31461138)



    vasopressin (bolus 4 IU) and i.v. infusion of 200 mL/h (vasopressin 2.4 IU/h) for 5 h after pts who received 6 units of product



     



    Vasopressors are associated with worse otucome after blunt trauma shock (PMID: 18188092), but little can be taken from this study



    Spahn, D.R., Bouillon, B., Cerny, V. et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 23, 98 (2019). https://doi.org/10.1186/s13054-019-2347-3

    If they are warm, give them vasoconstriction

     



     

    • 20 min

Customer Reviews

5.0 out of 5
1 Rating

1 Rating

Top Podcasts In Medicine

Listeners Also Subscribed To