Critical Care Scenarios

A vascular access roundtable, discussing our practices surrounding arterial lines, central lines, PICC lines and midlines, and PA catheters. When do we place them? When can they come out? What sites do we like? When (and how) do we use ultrasound? What’s up with the axillary site, why does Brandon hate PICCs, the age-old debate … <a href="https://icuscenarios.com/episode-29-lightning-rounds-2/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 29: Lightning rounds #2"</span></a>

How to take the well-resuscitated critically ill patient, get fluid out of them, deescalate their antibiotics, wean their sedation, reduce vent support, extubate, and get them out of the ICU—with Dr. Matt Siuba (Twitter: @msiuba), an intensivist at the Cleveland Clinic with an abiding interest in “zentensivism,” the art of doing less. Takeaway lessons Portal … <a href="https://icuscenarios.com/episode-28-diuresis-deescalation-and-liberation-with-matt-siuba/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 28: Diuresis, deescalation, and liberation with Matt Siuba"</span></a>

Management of an alpine medicine scene including discussion of HAPE (High Altitude Pulmonary Edema), HACE (High Altitude Cerebral Edema), and suspension syndrome, with Dr. Ross Hofmeyr (@rosshofmeyr), anesthesiologist in the Department of Anaesthesia and Perioperative Medicine at the University of Cape Town, as well as cofounder and medical director of WildMedix, the oldest wilderness medicine … <a href="https://icuscenarios.com/episode-25-wilderness-medicine-with-ross-hofmeyr/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 27: Wilderness medicine with Ross Hofmeyr"</span></a>

How to manage the intubated critically ill patient while keeping them awake, non-delirious, and mobile, with Dr. Dale Needham, FCPA, MD, PhD. Dr. Needham is a Professor of Pulmonary and Critical Care Medicine as well as Physical Medicine and Rehabilitation at the Johns Hopkins University. He is also director of their Outcomes After Critical Illness … <a href="https://icuscenarios.com/episode-26-icu-sedation-mobility-and-delirium-with-dale-needham/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 26: ICU sedation, mobility, and delirium with Dale Needham"</span></a>

Initial workup, fluid management, renal replacement, and other subtleties of caring for the critically ill patient with rhabdomyolysis. Takeaway lessons Rhabdomyolysis is defined by elevated levels of creatinine kinase and/or myoglobin in the serum secondary to skeletal muscle breakdown with release of cellular contents. Common causes are crush or compartment syndrome, prolonged downtime on hard … <a href="https://icuscenarios.com/episode-25-rhabdomyolysis/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 25: Rhabdomyolysis"</span></a>

The COVID-19 pandemic will hopefully wind down this year. What happens next with these patients? A powerful discussion with Eve Leckie (@browofjustice), RN, CCRN, formerly of the CVCC at Dartmouth-Hitchcock and now disabled after contracting COVID. Learn about their acute course of illness, the challenges of navigating the healthcare system with this new disease, and … <a href="https://icuscenarios.com/special-episode-surviving-covid-19-with-eve-leckie/" class="more-link">Continue reading<span class="screen-reader-text"> "Special episode: Surviving COVID-19 with Eve Leckie"</span></a>

Scene management, logistics, and stabilization of a blunt trauma patient in the Australian outback with Dr. Minh Le Cong (@ketaminh), rural GP and retrieval physician for the Royal Flying Doctor Service and host of the PHARM podcast. Takeaway lessons If there is reasonable suspicion of the presence of a pneumothorax (of any size), have a … <a href="https://icuscenarios.com/episode-24-rural-retrieval-medicine-with-minh-le-cong/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 24: Rural retrieval medicine with Minh Le Cong"</span></a>

Best practices in care of the critically ill patient with COVID-19 pneumonia are not known at this time. However, practical lessons from the ground are filtering in from those who have seen many of these patients, and Dr. Nicole King—critical care anesthesiologist, ECMO-ologist at the University of Cincinnati, and alumnus of the New York City … <a href="https://icuscenarios.com/episode-23-covid-19-pneumonia-with-nicole-king/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 23: COVID-19 pneumonia with Nicole King"</span></a>

Initial approach, supportive care, risk stratification, and management of the troublesome complications for ruptured subarachnoid aneurysm, with Thomas Lawson (@TomLawsonNP), nurse practitioner in the neurocritical care unit at OSU Wexner Medical Center. Takeaway lessons SAH + shock or hypoxemia = suspect neurogenic pulmonary edema and/or Takotsubo cardiomyopathy. Aneurysmal SAH is much different from traumatic and … <a href="https://icuscenarios.com/episode-22-aneurysmal-subarachnoid-hemorrhage-with-thomas-lawson/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 22: Aneurysmal subarachnoid hemorrhage with Thomas Lawson"</span></a>

A patient with multiple abdominal gunshot wounds, resuscitated before and after damage control surgery by the legendary Scott Weingart (@emcrit): emergency physician, surgical intensivist by way of Shock Trauma in Baltimore, director of an emergency critical care program, and longtime innovator in medical education and FOAM via the EMCrit podcast and blog. Our 1st anniversary … <a href="https://icuscenarios.com/episode-21-trauma-resuscitation-with-scott-weingart/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 21: Trauma resuscitation with Scott Weingart"</span></a>

Looking at the workflow of a fresh post-op open heart surgery patient, as well as what to do when it devolves into cardiac tamponade, with (returning) guest Brendan Riordan, cardiothoracic ICU PA (@concernecus) at the University of Washington, and his NP colleague Kris Ramilo (@krsrml0). [Audio quality was a bit dodgy in this one; sorry … <a href="https://icuscenarios.com/episode-20-post-cabg-emergencies-with-kris-ramilo-and-brendan-riordan/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 20: Post-CABG emergencies with Kris Ramilo and Brendan Riordan"</span></a>

A few rapid-fire cases from the emergency department, with Dr. Seth Trueger (@mdaware), emergency physician at Northwestern University and digital media editor for JAMA Network Open. [Sorry for the shotty audio quality in this one!–eds.] Takeaway lessons Many decisions in the ED are less about what to do, and more about when to do it. … <a href="https://icuscenarios.com/episode-19-emergency-medicine-with-seth-trueger/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 19: Emergency medicine with Seth Trueger"</span></a>

A look at oncology-related emergencies in the ICU, with Leon Chen (@CCMNP), NYC nurse practitioner specializing in oncology critical care. Takeaway lessons Extremely elevated leukocyte count should always raise suspicion for a “liquid tumor” such as leukemia. The principal acute complication is leukostasis from poor flow, potentially causing hyperviscosity issues such as stroke, MI, pulmonary … <a href="https://icuscenarios.com/episode-18-oncologic-emergencies-with-leon-chen/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 18: Oncologic emergencies with Leon Chen"</span></a>

The second part of our overview of interventional radiology with Dr. Bobby Chiong, board-certified interventional radiologist and chair of radiology at SBH Health System, with a focused look at some common IR procedures, namely abscess drainage and GI bleeding. Listen to part 1 here. Takeaway lessons Common goals would be INR <2.0, platelets >50k. If … <a href="https://icuscenarios.com/episode-17-interventional-radiology-with-bobby-chiong-part-2/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 17: Interventional radiology with Bobby Chiong (part 2)"</span></a>

An overview of interventional radiology with Dr. Bobby Chiong, board-certified interventional radiologist and chair of radiology at SBH Health System, with a focused look at what IR’s all about, coordination between care teams, vascular access, and troubleshooting. Takeaway lessons Interventional radiologists can’t do everything, but they potentially can do almost anything, and you usually won’t … <a href="https://icuscenarios.com/episode-16-interventional-radiology-with-bobby-chiong-part-1/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 16: Interventional radiology with Bobby Chiong (part 1)"</span></a>

Quick takes on common controversies in the ICU, with Bryan and Brandon: Stress ulcer prophylaxis: drug selection, candidates, and when to discontinue Stress dose steroids: candidates, dosing, lab tests, and weaning Titrating PEEP: considering the disease process, PEEP/FiO2 tables, driving pressure trials, and pragmatic approaches

A detailed look at cirrhosis and acute-on-chronic liver failure as we typically see it in the ICU, with Dr. Elliott Tapper, gastroenterologist and transplant hepatologist, and director of the cirrhosis program at the University of Michigan in Ann Arbor. Takeaway lessons When treating liver patients, think infection, infection, infection—and understand that with good care and … <a href="https://icuscenarios.com/episode-15-liver-failure-with-elliott-tapper/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 15: Liver failure with Elliott Tapper"</span></a>

The conclusion of our scenario of severe intraparenchymal hemorrhage with resulting herniation, with a closer look at neurological exams, prognostication, and the flow of care after initial stabilization, as well as our mindset as caregivers in these psychologically challenging cases. Takeaway lessons Early tracheostomy may not hold concrete benefits for neuro patients (i.e. improved mortality), … <a href="https://icuscenarios.com/episode-14-intracerebral-hemorrhage-and-elevated-icp-part-2/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 14: Intracerebral hemorrhage and elevated ICP (part 2)"</span></a>

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 … <a href="https://icuscenarios.com/episode-13-intracerebral-hemorrhage-and-elevated-icp-part-1/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 13: Intracerebral hemorrhage and elevated ICP (part 1)"</span></a>

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 … <a href="https://icuscenarios.com/episode-11-flight-medicine-with-tyler-christifulli-and-sam-ireland-part-2/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 12: Flight medicine with Tyler Christifulli and Sam Ireland (part 2)"</span></a>

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 … <a href="https://icuscenarios.com/episode-11-flight-medicine-with-tyler-christifulli-and-sam-ireland/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 11: Flight medicine with Tyler Christifulli and Sam Ireland (part 1)"</span></a>

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 Takeaway lessons Start with ABCs and stabilizing the patient, then put on your thinking cap and try to optimize … <a href="https://icuscenarios.com/episode-10-ventilator-dyssynchrony/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 10: Ventilator dyssynchrony"</span></a>

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 href="https://icuscenarios.com/episode-9-right-heart-failure-and-the-savior-protocol-with-habib-srour-part-2/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 9: Right heart failure and the SAVIOR protocol with Habib Srour (part 2)"</span></a>

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 … <a href="https://icuscenarios.com/episode-9-right-heart-failure-and-the-savior-protocol-with-habib-srour-part-1/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 9: Right heart failure and the SAVIOR protocol with Habib Srour (part 1)"</span></a>

The second part of our look at a case of catastrophic intracranial hemorrhage, with a focus on goals of care, family interaction, prognostication, and other end-of-life aspects, with neurointensivist and palliative care physician Jess McFarlin (@JessMcFarlinMD). See Part 1 here. Takeaway lessons Useful phrase: “Can I tell you what to expect during the dying time?” … <a href="https://icuscenarios.com/episode-8-palliative-care-with-jessica-mcfarlin-part-2/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 8: Palliative care with Jessica McFarlin (part 2)"</span></a>

Neurointensivist and palliative care physician Jess McFarlin (@JessMcFarlinMD) walks us through a case of catastrophic intracranial hemorrhage, with a focus on goals of care, family interaction, prognostication, and other end-of-life aspects. See Part 2 here. Takeaway lessons We can undo most things except death, so in most cases, a short trial (perhaps 3 days) of … <a href="https://icuscenarios.com/episode-7-palliative-care-with-jessica-mcfarlin-part-1/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 7: Palliative care with Jessica McFarlin (part 1)"</span></a>

Neurologist and neurointensivist Gracia Mui shows us the workup, initial management, and escalation of care for a case of refractory status epilepticus. Takeaway lessons First-time unprovoked seizures usually need no further workup except screening for an underlying trigger, such as a tox screen, basic chemistries, and imaging as appropriate. Initial seizure therapy: wait around 5 … <a href="https://icuscenarios.com/episode-6-status-epilepticus-with-gracia-mui/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 6: Status epilepticus with Gracia Mui"</span></a>

Cardiothoracic critical care PA Brendan Riordan (@concernecus) shows us his initial approach to the patient in cardiogenic shock, including initiating mechanical support, managing ECMO (plus Impella), and eventual weaning and discontinuation of support. Some pearls Anticoagulation on VA ECMO can be titrated to bleeding risk, with a balance between bleeding and circuit longevity—the latter being … <a href="https://icuscenarios.com/episode-5-cardiogenic-shock-and-ecmo-with-brendan-riordan/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 5: Cardiogenic shock and ECMO with Brendan Riordan"</span></a>

A fast-tracked update: what we know about the active pandemic of the novel coronavirus (SARS-CoV-2) and its resulting respiratory syndrome, COVID-19. Takeaway lessons Treat like viral pneumonia/ARDS. High PEEP. Prone early. Keep fluid balance dry. Probably avoid CPAP/BiPAP except perhaps for very short trials. Unclear role for HFNC. Watch out for myocarditis-type picture with cardiogenic … <a href="https://icuscenarios.com/special-episode-covid-19-bri/" class="more-link">Continue reading<span class="screen-reader-text"> "Special episode: COVID-19 brief"</span></a>

Intensivist and passionate slayer of venous congestion Philippe Rola (@thinkingcc) shows us how to deresuscitate the septic patient, with guidance from his handy ultrasound. Takeaway lessons Fluid overload is harmful and should be actively reduced, even in a patient in active shock; it will not harm them. The VEXUS exam is a good method for … <a href="https://icuscenarios.com/episode-4-venous-congestion-with-philippe-rola/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 4: Venous congestion with Philippe Rola"</span></a>

What stops do you make along the garden path of hypoxic respiratory failure? Resources References An ARDS review: Fan E, Brodie D, Slutsky A. Acute Respiratory Distress: Syndrome Advances in Diagnosis and Treatment. JAMA. 2018;319(7):698-710 Lung protective ventilation (The original ARDSnet ARMA trial): Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, et al. Ventilation with … <a href="https://icuscenarios.com/episode-3-refractory-ards/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 3: Refractory ARDS"</span></a>

A tricky case of refractory heart failure. Case files Resources References Champion S, Belcour D, Vandroux D, et al. Stress (Tako-tsubo) cardiomyopathy in critically-ill patients. Eur Heart J. 2015;4(2):189-96. Chockalingam A. Stress cardiomyopathy of the critically ill: Spectrum of secondary, global, probable and subclinical forms. Indian Heart J. 2018;70(1):177-84. Dawson D. Acute stress-induced (takotsubo) cardiomyopathy. … <a href="https://icuscenarios.com/episode-2-takotsubo-stress-cardiomyopathy/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 2: Takotsubo (Stress) Cardiomyopathy"</span></a>

A troubling case of a painful finger. Resources References Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 7;377(23):2253-2265. Bechar J, Sepehripour S, Hardwicke J, Filobbos G. Laboratory risk indicator for necrotising fasciitis (LRINEC) score for the assessment of early necrotising fasciitis: a systematic review of the literature. Ann R Coll … <a href="https://icuscenarios.com/episode-1-necrotizing-soft-tissue-infection-2/" class="more-link">Continue reading<span class="screen-reader-text"> "Episode 1: Necrotizing Soft Tissue Infection"</span></a>

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