These books from @accpchest & @SCCM represent my study goal for this month. Before starting any (re-)certification exam & especially f you want to ace the tests, there are a few recent trends (& old habits/tricks) that you need to be aware of:
1. If there is an option of "doing nothing", this is most likely the correct answer. 2. There is always a mixed metabolic disorder. Memorize Winter's formula. 3. Prepare for several COVID-19-related questions. No surprise here...
4. TEG is very popular. Even of you are a dinosaur, you have to learn the basics about visco-elastic tests. 5. I know you have no CAR T-cell therapies in your hospital (& no one can really spell them correctly), but be prepared for managing cytokine release syndrome.
If you don't know anything, just remember what we do in COVID-19: steroids + toclizumab. 6. There is always a chest x-ray with a well hidden finding. You will never find it anyway because the image quality sucks, but use it as an opportunity to schedule your annual vision test.
7. Read a little bit about ECMO. You may not know which button to push on your ICU's ventilator to check for auto-PEEP, but you are expected to recognize an ECMO circuit oxygenator clot (and change it) in a heart beat. 8. There is always a question about Hantavirus
pulmonary syndrome (HPS). Even though HPS is a disorder that 99.9% of intensivists will never have to manage during their clinical career, it is a question that 100% of intensivists will encounter during their test-taking career. 9. Please learn the mechanical complications of
myocardial infarction. I know that last time you placed a Swan was before the Connors' study, but the examiners think you sleep w a Swan under your pillow. So, you better know what these V waves mean. 10. Induced hyperlipidemia can save a life. Commit this piece of info to memory
Thanks for reading & keep following for live coverage as I am browsing these books. Now I will open the first one of them!
ICU stories: 65 yo pt, fairly healthy besides HTN & an episode of diverticulitis 3 y ago, is brought to the ED due to 2 wks' hx of abd pain & 1 d hx of N/V ("coffee-ground"). Looked "bad". SBP in 60s - improved to 80s w ivf. Intubated. Had CT A/P 👇:
While you review the CT images, you get the lab results: Lactate 10, WBC 3K, INR 2.0, BUN/Creat 100/3.0, CRP 500 mg/l, Procalcitonin 300. The ED is calling you for the admission. What consult(s) do you ask?
The CT A/P showed a large amount of free intra-peritoneal air; stomach & SB were mildly distended & partially fluid-filled. There was colonic diverticulosis without diverticulitis & mild wall thickening involving the descending colon & the sigmoid colon
ICU stories: 70 yo pt without medical hx but tobacco use (2 ppd x 40 y) was admitted w shortness of breath a wk ago. CXR/chest CT without PE/infiltrate. Was in afib/RVR on admission; placed on heparin & dilt/b-blocker (w some hypotension). Remained dyspneic, at times restless,
“requiring” multiple sedatives, & eventually was brought to the ICU. Intubated for "resp distress" & mental status changes. "Formal" echo, the day of ICU transfer, showed “LVEF 20% w global LV dysfunction”. On the vent 50% - peep 10. BP 110-130/60-70. Lactate < 2.0
Cards follow for "well compensated heart failure". A look w POCUS upon ICU admission:
How do you examine the lower extremity venous system when you look for deep vein thrombosis? What points do you check with the probe? Do you use Doppler? What are the recommended protocols? The Society of Radiologists in Ultrasound recommends a complete duplex ultrasound:
👆 The black rectangles represent the extent of the compression US. The gray rectangles are the sites of Doppler.
2-CUS (2-points compression US) includes compression of the femoral veins 1-2 cm above & below the saphenofemoral junction & the popliteal veins
up to the calf veins
ECUS (extended compression US), includes compression US from the common femoral vein through the popliteal vein up to the calf veins confluence
CCUS (complete compression US), includes compression US from the common femoral vein to the ankle
Following up on a discussion during ICU rounds this am: Like most laboratory values in medicine, pH and lactate levels should be evaluated in their context. In this 👇 old study of 6 male oarsmen who participated in a maximal effort on a rowing ergometer,
the two lowest pH values were 6.74 and 6.76 (corresponding to [H+] of > 180 nmol/L); the HCO3 levels were undetectable. The lowest lactate level was 32 mmol/l. The oarsmen remained conscious and did not require medical help
The conclusion of the study was that "in healthy humans, pronounced, but transient,acidosis is well-tolerated". Finding a pH of 7.05 or a lactate of 10 is usually not a big deal in a patient with DKA or (post-)seizures
ICU stories (a boring one…): If you work in a general ICU of a community hospital in United States, one of the common admissions you will get is the unfortunate resident of a nursing home or rehabilitation center that lives there for several decades & at some point becomes
febrile/“altered” & is sent to the ED for “evaluation”. The course is so predictable that we usually consider these admissions “boring”. This is the case of a middle-aged pt w cerebral palsy/mental retardation/seizures (on valproic)/PEG-chronic Foley in place who was sent to
the ED for fever+hypotension+tachycadia. Labs: WBC 15k, lactate 4.0. UA -as usually- suggestive of UTI (WBC>50, +bacteria, +nitrite, +esterase). CXR “clear” & pt w sat 99% on room air. Received ivf, Abx (pip/tazo + vanco) but due to persistent ⬇️BP, norepinephrine gtt was ordered
It's December, already. The time of the year when I am trying to spend every last cent of the annual allowance given to us for continuing medical education (CME) by our employer. In essence, this is money that we have worked for and, since it won't carry over to next year, I hate
leaving it on the table. The problem is that if you buy a conference or a study course now, you have to watch everything - and submit proof of attendance/completion - before the end of the year. So, it's a very busy month dedicated to studying/reviewing educational material!
For example, I just finished watching the last one of the 93 lectures from The Hospitalist & Resuscitationist 2022 conference #HR2022. If you are an intensivist/internist/family medicine/EM physician, I have no doubt that u will find several pearls to bring back to your practice