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IMCrit

@IM_Crit_

Feb 25

ICU stories (from the trenches): 70 yo pt w hx of A-fib/CAD/ICM w EF 25%/VT ablation s/p BiV ICD/CKD/HTN/HLD/peripheral vasc dz/COPD etc presented to outside 🏥 w SOB/weakness/falls. Labs: wbc 15k/creat 3.5 (baseline 2.0)/INR: 8.5/AST/ALT/Tbil: 180/250/3.0, lactate 3.5

RUQ US was obtained to work-up elevated LFTs:

Diagnosed w bilateral PNA/AKI/liver dysfunction. Treated for sepsis w ivf boluses, broad-spectrum antibiotics, steroids, bicarb. Continue to get worse; due to ⬆️O2 needs, transferred to our 🏥. I saw her the next am: in resp distress while on BiPAP 15/10-100%, abg 7.26/50/70/19.

Read 30 tweets

IMCrit

@IM_Crit_

Feb 4

ICU stories (a common one): It's Saturday, Jan 28, 2023. You just came on service at 7:00 am & at the same time, they were rolling in a case from the OR (Friday night case = never good...). 65 yo pt w DM2/diastolic HF/CAD/A fib/HTN/PVD. Had 10 ds' hx of abd pain; CT A/P showed

evidence of ischemic bowel. Pt came to the ICU after an exp-laparotomy w partial small bowel resection. The gut was left in discontinuity & the abdomen was left open. Pt still sedated & paralyzed, on norepi 0.18. A sleep-deprived anesth CRNA is telling you that the surgeon plans

to bring the pt back to OR for 2nd look on Monday. You feel so lucky; pt already has lines from the OR, you just have to keep him sedated for 2 days. Piece of cake! You move on to the other pts but the RN interrupts your dream rounds in 5 min. What about maintenance fluids, doc?

Read 19 tweets

IMCrit

@IM_Crit_

Jan 29

ICU stories (a brief one): One hour before the end of the am shift, u walk around in the ICU to make sure thinks look OK before u type your sign-out note. You spot the resp therapist & the nurse bagging the pt in Rm 306. From the hallway, u see the monitor: HR 160, RR/45, Sat 70%

This is a 30 yo pt w hx of a catastrophic brain bleed, s/p trach & PEG, admitted 2 wks ago w MDR Klebsiella UTI. Doing well, on trach mask 28%, until the episode of acute/unexpected desaturation

When u examine the pt, s/he is in extremis (accessory muscle use-tachycardic-tachypneic-diaphoretic). BP: 105/55. You grab the stethoscope that the resp therapist wears around his neck & you hear breath sounds in both sides (pt is skinny...)

Read 24 tweets

IMCrit

@IM_Crit_

Jan 15

https://twitter.com/IM_Crit_/status/1614457555568234501

Judging from yesterday's post, many friends are interested in how to get the most out of these books 👇 and ace the exams, so a few more tips are on their way:

https://twitter.com/IM_Crit_/status/1614457555568234501

1. Tylenol use can lead to high anion gap metabolic acidosis. Don’t ask me about the mechanism!
2. Every patient who manages to fly eastbound with Southwest Airlines & subsequently develops pneumonia not responding to common antibiotics has actually blastomycosis

3. Every oncology patient who receives chemo is destined to develop tumor lysis syndrome. Please learn about hydration/allopurinol/rasburicase
4. Along these lines, every oncology patient on immunotherapy will develop pneumonitis. Remember the steroids from yesterday’s post?

Read 8 tweets

IMCrit

@IM_Crit_

Jan 15

@accpchest

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.

Read 9 tweets

IMCrit

@IM_Crit_

Jan 13

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

Read 13 tweets

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