Critical Care Scenarios

Ensuring patient and operator safety with Seldinger guidewires, with considerations such as losing wires, transecting them, and perforating vessels.

Brandon and Bryan chat about tricks and methods of increasing efficiency and getting things done at work.

A deep dive into dilation during Seldinger techniques, such as central line placement: tips, pitfalls, and pearls.

We explore the controversial area of using hypertonic saline to support hemodynamics, protect the kidneys, and facilitate diuresis in the critically ill patient. Our guest is Dr. Sean Barnett, hypertonic aficionado and nephrologist with a focus in critical care. Takeaway lessons The furosemide stress test in the shocked patient is a useful means to assess … <a href="https://icuscenarios.com/episode-51-resuscitating-and-deresuscitating-with-hypertonic-saline-with-sean-barnett/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 51: Resuscitating and deresuscitating with hypertonic saline, with Sean Barnett"</span></a>

Ruminations on nursing post-nominals, understated wealth, and how it’s easiest to not show your power when you already plenty of it.

Continuing the discussion from last Lightning Rounds about presenting at conferences, Brandon and Bryan chat about writing for peer-reviewed journals: why, how, and the process from choosing co-authors to choosing journals to navigating the submission.

How do PAs and other APPs compare with physicians in the clinical context?

We look at the rib fracture patient requiring ICU admission, including a discussion of surgical repair, with Dr. Ron Barbosa (@rbarbosa91), Portland trauma surgeon and SICU director at Legacy Emmanual Medical Center. Takeaway lessons Algorithms and protocols for admitting disposition exist but are generally poorly predictive. ICU admission in rib fracture patients is still most … <a href="https://icuscenarios.com/episode-50-rib-fractures-and-surgical-plating-with-ron-barbosa/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 50: Rib fractures and surgical plating with Ron Barbosa"</span></a>

Brandon and Bryan chat about academic presentations… how to prepare and submit them, selecting the right venue, giving a good talk, and the elephant in the room: why to do it at all.

How the arc of disease peaks and falls, and how the curve of our care should match it to avoid under- or over-treatment.

We discuss invasive aspergillosis, with a focus on when to consider and how to make this difficult diagnosis in the general ICU population—with Dr. Shmuel Shoham (@ShohamTxID), Associate Professor of Medicine at Johns Hopkins, transplant infectious disease physician, and an extensively published expert in invasive fungal infections as well as host of the Transplant ID … <a href="https://icuscenarios.com/episode-49-invasive-pulmonary-aspergillosis-with-shmuel-shoham/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 49: Invasive pulmonary aspergillosis with Shmuel Shoham"</span></a>

Time is always a factor in the ICU, but some time matters more than other time.

Brandon and Bryan share their approaches to the chest x-ray in the ICU. Plus: Bryan’s an FCCM! Here’s the Radiology Masterclass.

Some musings in response to people who are impressed by the work we do.

Brandon walks Bryan through a case of new, unexplained hypotension in the ICU, with a focus on approaching shock, the use of POCUS, and risk stratifying unexplained problems. Takeaway lessons Sudden changes in vital signs or other status are often due to precipitating factors, such as iatrogenic stimuli, whereas more gradual changes are often due … <a href="https://icuscenarios.com/episode-48-undifferentiated-hypotension/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 48: Undifferentiated hypotension"</span></a>

Advanced techniques for manipulating the guidewire during non-fluoroscopic bedside procedures such as central line placement.

Brandon and Bryan talk about how they assemble, implement, and leverage case-based learning, from this podcast to simulation to oral scenarios to internal visualization.

When it’s a bad idea to help out others with their work.

Discussing ICU triage, risk stratification, and patient disposition with intensivist Eddy Joe Gutierrez (@eddyjoemd) of the Saving Lives Podcast. For 20% off the upcoming Resuscitative TEE courses (through July 23, 2022), listen to the show for a promo code for CCS listeners! Takeaway lessons When a patient has borderline indications for requiring the ICU, generally, … <a href="https://icuscenarios.com/episode-47-icu-triage-with-eddy-gutierrez/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 47: ICU triage with Eddy Gutierrez"</span></a>

A selection of lesser-known quotes relevant to the practice of medicine.

Bryan and Brand talk about night shifts, how to handle them, managing the disruption of your circadian rhythm, and more. For 20% off the upcoming Resuscitative TEE courses (through July 23, 2022), listen to the show for a promo code for CCS listeners!

The relationship between skin warmth and color, cardiac output, and systemic vascular resistance. For 20% off the upcoming Resuscitative TEE courses (through July 23, 2022), listen to the show for a promo code for CCS listeners!

We review a case of massive intraparenchymal hemorrhage progressing to brain death, including the process of brain death testing and declaration, with Dr. Casey Albin (@CaseyAlbin), neurologist and neurointensivist, assistant professor of Neurology and Neurosurgery at Emory and part of the NeuroEmcrit team. For 20% off the upcoming Resuscitative TEE courses (through July 23, 2022), … <a href="https://icuscenarios.com/episode-46-neurologic-catastrophe-and-brain-death-with-casey-albin/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 46: Neurologic catastrophe and brain death with Casey Albin"</span></a>

A practical approach to choosing and escalating vasopressors for patients in shock.

Brandon and Bryan discuss a practical approach to abdominal compartment syndrome: when to suspect it, confirming the diagnosis with bladder pressure or other monitoring, management, and prognosis. Sorry for the audio on this one!

Reviewing the different approaches to placing central venous catheters in the subclavian vein.

We discuss the clinical presentation and management of AFE with guests Dr. Stephanie Martin (Twitter: @OBCriticalCare, Instagram: @criticalcareob), medical director for Clinical Concepts in Obstetrics and a Maternal Fetal Medicine specialist in Scottsdale, Arizona with expertise in critical care obstetrics. She is also co-host of the Critical Care Obstetrics podcast. We’re also joined for a … <a href="https://icuscenarios.com/episode-45-amniotic-fluid-embolism-with-stephanie-martin/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 45: Amniotic fluid embolism with Stephanie Martin"</span></a>

A look at rehabilitation and mobility in the critically ill, from the perspective of our skilled therapists—with Heidi Engel, PT, DPT of UC San Francisco, long-term provider of acute care therapy, researcher in ICU rehabilitation, and founding member of the SCCM’s ICU Liberation program. Takeaway lessons Tolerance of pressure support ventilation is often a good … <a href="https://icuscenarios.com/episode-44-physical-therapy-with-heidi-engel/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 44: Physical therapy with Heidi Engel"</span></a>

A quick review of tracheoinnominate fistulas: how they happen, what they look like, and most importantly, what you’ll need to do.

Brandon and Bryan reflect on the qualities that define good and bad ICU nurses, the challenges they face, and how APPs and physicians can enable them to be their best.

Why an assumption in your training should be to call for assistance, but expect it will never arrive. Plan to manage problems yourself. Let help surprise you—otherwise hope becomes your plan.

The hows, whys, logistics, and applications of focused, bedside transesophageal echocardiography performed by critical care and EM providers, with Felipe Teran, assistant professor of emergency medicine at Weill Cornell and director of the Resuscitative TEE Project. Takeaway lessons As a rule, resuscitative TEE is performed in patients with a secured airway. TEE views are not … <a href="https://icuscenarios.com/episode-43-resuscitative-tee-with-felipe-taran/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 43: Resuscitative TEE with Felipe Teran"</span></a>

When do interventions need to be “weaned”? Stop using this word when you don’t mean it! Titrate, target to effect, but only wean when there is a physiologic dependence.

Brandon and Bryan talk about the practicalities of communication, collaboration, and compromise in a surgical ICU, when the surgical and critical care teams are both involved, one is the “primary” team on paper, but everyone needs to be heard.

When should you place a line or perform other procedures using your left (or non-dominant) hand? Brandon reflects on a few situations.

The first episode of Brandon’s intermittent solo rants, in this case discussing toughness, stress tolerance, and flexibility in clinical medicine.

An overview of the role and contributions of a clinical pharmacist in the ICU, with Laura Means Ebbitt of the University of Kentucky, a clinical pharmacist specializing in colorectal/ENT surgery and critical care. Takeaway lessons A clinical pharmacist is a “knowledge pharmacist,” dispensing advice rather than medications. They round with the team to review meds … <a href="https://icuscenarios.com/episode-42-clinical-pharmacists-with-laura-means-ebbitt/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 42: Clinical pharmacists with Laura Means Ebbitt"</span></a>

Bryan and Brandon look back on the two-year anniversary of the show and reflect on where it’s been, where it’s going, lessons learned, and other deep thoughts.

Part two of our discussion with fan favorite Matt Siuba (@msiuba), Cleveland Clinic intensivist, on complications in critical care and how to prevent and manage them. Today we focus on respiratory failure after extubation, and unintentional self-extubation. Takeaway lessons When considering extubation of borderline patients, extubating to high flow nasal cannula or CPAP/BiPAP is often a good … <a href="https://icuscenarios.com/episode-41-preventing-and-managing-complications-part-2-with-matt-siuba/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 41: Preventing and managing complications (part 2) with Matt Siuba"</span></a>

Bryan and Brandon talk about the physical exam: how we apply it in the ICU, its utility and changing role in the setting of modern diagnostic modalities, and its best and most practical use-cases. References McNamara LC, Kanjee Z. Counterpoint: Routine Daily Physical Exams Add Value for the Hospitalist and Patient. J Hosp Med. 2021 … <a href="https://icuscenarios.com/lightning-rounds-10-physical-examination-in-the-icu/" class="more-link">Continue reading<span class="screen-reader-text"> "Lightning rounds #10: Physical examination in the ICU"</span></a>

Dr. André Mansoor (@AndreMansoor), associate professor of medicine in Portland, Oregon, author of the excellent Frameworks for Internal Medicine, and contributor to Physical Diagnosis PDX, talks us through a complex case of encephalopathy and respiratory failure to illustrate some principles of diagnostic reasoning. Takeaway lessons The hardest part of treating most diseases is making the … <a href="https://icuscenarios.com/episode-40-making-the-diagnosis-with-andre-mansoor/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 40: Making the diagnosis with André Mansoor"</span></a>

Bryan and Brandon chat about notes: what makes a good one, their many and conflicting purposes, some structures and approaches, system- versus problem-based charting, and more.

An overview of VV ECMO with a focus on COVID-19, with Dr. Kimberly A. Boswell (EM and CCM) of the University of Maryland, perhaps the busiest center in the country for COVID-related ECMO. We discuss evaluating for candidacy, induction, maintenance, weaning, and general approaches to the COVID patient. Takeaway lessons The limited amount of ECMO … <a href="https://icuscenarios.com/episode-39-ecmo-for-covid-19-with-kim-boswell/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 39: ECMO for COVID-19 with Kim Boswell"</span></a>

Bryan’s off this week, so Brandon flies solo to explain five wrong-headed notions that many people believe without thinking about them. Are diuretic infusions more effective than intermittent boluses? Are antipsychotic (neuroleptic) agents a good treatment for ICU delirium? Is pressure control or volume control a better form of assist control? Does renal failure cause … <a href="https://icuscenarios.com/lightning-rounds-8-five-things-youre-getting-wrong/" class="more-link">Continue reading<span class="screen-reader-text"> "Lightning rounds #8: Five things you’re getting wrong"</span></a>

Back with returning guest Dr. Elliot Tapper (@ebtapper), gastroenterologist, transplant hepatologist, and director of the cirrhosis program at the University of Michigan in Ann Arbor, to talk about critical GI bleeding. Takeaway lessons Consider the Glasgow-Blatchford score to stratify risk and need for admission, GI consultation, etc. Octreotide (or terlipressin) is indicated in every cirrhotic … <a href="https://icuscenarios.com/episode-38-gi-bleeding-with-elliot-tapper/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 38: GI bleeding with Elliot Tapper"</span></a>

Discussing a pickle of a topic: outside of academic milestones, how do we recognize, acknowledge, reward, and move towards clinical excellence in medicine after one’s training is complete? In fact… do we?

Back again with Dr. Ross Hofmeyr (@rosshofmeyr), anesthesiologist in the Department of Anaesthesia and Perioperative Medicine at the University of Cape Town, to discuss an expert’s perspective on airway management in the COVID-19 patient. Takeaway lessons Good practices for intubating COVID patients are, by and large, good practices for intubating anybody. Using a standardized protocol, … <a href="https://icuscenarios.com/episode-37-airway-management-for-covid-19/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 37: Airway management for COVID-19"</span></a>

We chat about focused, clinician-performed point-of-care ultrasound (POCUS) in the ICU. How do you learn it? What are our favorite applications? What are some of the particulars and caveats surrounding credentialing, documentation, and billing? All that and more…

Back in the arena with one of our favorites, Matt Siuba (@msiuba), Cleveland Clinic intensivist and Mr. Zentensivism, to discuss complications in critical care and how to prevent and manage them. Today we focus on atrial fibrillation with RVR and bleeding after thoracentesis and related other procedures. Takeaway lessons Rapid atrial fibrillation in the ICU … <a href="https://icuscenarios.com/episode-36-preventing-and-managing-complications/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 36: Preventing and managing complications"</span></a>