“Hot & Bothered” Hyperthermic Toxidromes

#criticalCare #toxicology #fever

Five potentially life threatening toxidromes (sympathomimetic overdose, anticholinergic overdose, serotonin syndrome, neuroleptic malignant syndrome, and malignant hyperthermia) can all present with overlapping clinical features: hyperthermia, altered mental status/seizures, rhabdomyolysis. Careful history and physical exam are essential to differentiate and a combination of supportive care (ABCs, cooling, etc) and specific therapies can be life-saving. This OnePager reviews the features of each with historical/exam pearls to differentiate.

Current version 1.0 (originally posted 2021-10-20).

Tracheostomy Emergencies

#criticalCare #airway #oxygenation #ventilation #hemorrhage

Tracheostomies are artificial airways that are inserted in the subglottis directly into the trachea. They are used in the setting of prolonged ventilation or as an emergency airway in the event of being unable to intubate from above. This OnePager reviews the components of a tracheostomy and an approach to managing tracheostomy emergencies, broken down into 3 categories: obstruction, decannulation, and bleeding.

Current version 1.0 (originally posted 2021-07-16). Also available in 🇪🇸Spanish (PDF, PNG, PPT)

Pulmonary Renal Syndromes

#pulmonary #rheumatology #criticalCare #nephrology

Pulmonary Renal syndromes are both complex and potentially life threatening, making rapid and accurate diagnosis essential but challenging. This ICU OnePager reviews the pathogenesis and differential diagnosis, including ANCA vasculitis (GPA, MPA, EGPA), anti-basement membrane disease (anti-GBM), as well as other diseases that can present similarly (SLE & other rheum diseases), and infections. It also explains how diffuse alveolar hemorrhage (DAH) is diagnosed and how to interpret ANCA testing and renal pathology.

Current version 1.0 (originally posted 2021-06-04).

Determining Fluid Responsiveness

#criticalCare #POCUS #resuscitation #shock #fluids #monitoring

Fluids are beneficial when needed but harmful in excess. Determining when to give fluids is a foundational critical care skill. This ICU OnePager reviews how to measure CO including invasive techniques (pulse pressure variation, pulse contour analysis, pulmonary artery catheters), ultrasound techniques (LVOT and carotid VTI, IVC distensibility) and less invasive technqiues (NICOM, End-Tidal CO2, etc). It also discusses the maneuvers that we can perform to test for fluid responsiveness: Passive Leg Raise (PLR), Mini-bolus, PEEP challenge, and End-Expiratory Occlusion (EEO). As a bonus, we talk about emerging techniques (fluid tolerance testing, VEXUS) as well as some techniques that just refuse to die (CVP, IVC size, PCWP, etc)

Current version 1.0 (originally posted 2021-03-22). Also available in 🇪🇸Spanish (PDF, PNG, PPT)

Overview of Renal Replacement Therapy

#criticalCare #nephrology #hemodialysis #ultrafiltration #RRT #CRRT

Renal replacement therapies are commonly used in the ICU to remove excess fluid and clear the blood of endogenous and exogenous toxins. This ICU OnePager explains the physics & physiology of dialysis, discussing the key concepts (dialysis = diffusion, hemofiltration/ultrafiltration = convection) and the components of the dialysis circuit (pumps, dialyzer, dialysis solution, replacement fluid, etc). It also reviews all the confusing modes of dialysis: IHD, SLED, and CRRT including SCUF, CVVHF, CVVHD, and CVVHDF.

Current version 1.0 (originally posted 2021-02-17). Also available 🇷🇴 Romanian (PDF, PPT, PNG)

Minnesota Tubes for Upper GI Bleeds

#criticalCare #gastroenterology #hemorrhage #resuscitation

Occasionally medical and interventional therapies can’t stop an upper GI bleeds due to esophageal varices. In those rare cases, placement of a Minnesota Tube can be life-saving. This #OnePager reviews how Minnesota Tubes work & shows you how to safely place and secure them. There are also some great how-to videos that walk you through the process step by step.

Current version 1.0 (originally posted 2021-01-29).

Temporary / External Cardiac Pacing

#criticalCare #hemodynamics #ICUequipment

External cardiac pacing is a technique for temporarily treating brady- and tachydysryhthmias in the ICU. This #OnePager covers the basics, including types of pacing leads (transvenous vs epicardial, bipolar vs unipolar), pacing modes (VVI, DDD, etc), and a stepwise guide to initiating pacing.

Current version 1.1 (originally posted 2021-01-22; updated 2021-01-25).

Non-invasive positive pressure ventilation

#criticalCare #ventilation #ICUequipment #oxygenation #waveforms

Non-invasive positive pressure ventilation (NIPPV) is a valuable technique to support oxygenation and ventilation in people with respiratory failure to potentially avoid intubation. This #OnePager reviews when to (and when not to) use NIPPV, as well as modes (CPAP, BiPAP/BiLevel, & AVAPS) and interfaces (nasal, partial face, full face, & helmet).

Current version 1.1 (originally posted 2020-01-02; updated 2020-05-30).

Also available in 🇪🇸Spanish (JPEG)

Pulse Oximetry

#criticalCare #ICUequipment #oxygenation #waveforms #monitors

We use pulse oximetry on every patient every day in the ICU, but how does this machine actually work and, importantly, how does it fail? This ICU #OnePager reviews the principle of pulse oximetry and the many factors that can cause inaccurate readings: darker skin pigmentation, nail polish, low flow states (ECMO & LVADs), and abnormal hemoglobins (MetHB, COHb, etc). It introduces the important concept of pulse ox lag-time and also shows how the waveform can provide useful physiologic clues about vascular tone/compliance.

Current version 1.0 (originally posted 2020-12-17). Also available in 🇵🇹🇧🇷 Portuguese..

Capnography Explained

#criticalCare #ICUEquipment #ventilation #waveforms #monitors

Measuring exhaled carbon dioxide (End Tidal CO2, ETCO2) is an important ICU technology that can used to confirm ETT placement, to ensure safer procedural sedation, to guide ACLS/resuscitation, and to monitor cardiac and pulmonary physiology in realtime. This ICU OnePager describes the physiology, equipment, waveforms you will see with ETCO2 monitoring.

Current version 1.1 (originally posted 2020-11-15; updated 2020-11-18).

Also available in 🇪🇸🇦🇷 Spanish (PDF, PNG, PPT) & 🇷🇴 Romanian (PDF, PNG, PPT)

Achieving a Negative Fluid Balance

#criticalCare #nephrology #fluids #diuresis #RRT

Volume overload is very common in the later stages of critical illness, and achieving a negative fluid balance is key to helping patients liberate from mechanical ventilation and ultimately recover. I outline strategies for minimizing ins (avoid MIVF, use high concentration drips, switch IV to PO) and maximizing outs (stepwise diuresis with loop diuretics, thiazides, spironolactone, and acetazolamide). I also discuss special circumstances including cirrhosis, nephrotic syndrome, and hypoalbuminemia.

Current version 1.4 (originally posted 2020-10-21; updated 2020-10-23) Also available in 🇫🇷 French (PDF)

Arterial lines & Waveforms

#hemodynamics #ICUEquipment #waveforms

Arterial lines are commonly used in the ICU for sampling arterial blood and for invasive hemodynamic monitoring. This ICU OnePager shows you how arterial lines work, teaches you how to troubleshoot them, and reviews some of the common (and not so common) diagnostic clues hidden in the arterial pressure waveform.

Current version 1.0 (2020-09-14). Also available in 🇪🇸Spanish (PNG, PDF, PPT)

Vasopressors Demystified

#criticalCare #hemodynamics #vasopressors #shock

Shock comes in many flavors and so do vasopressors. Here’s a #OnePager summarizing my approach to pressors including when to start, which ones to use, how to administer them, and when to increase or wean. Includes my favorite pedagogical device for vasopressor: the pressor-speedometer from beta to alpha adrenergic effects..

Current version 1.2 (updated 2021-02-23). Also available in 🇪🇸Spanish (JPEG) & 🇩🇪 German (PDF, PNG, PPT)

Chest Drains Made Simple

#criticalCare #pulmonary #pneumothorax #shock #ICUEquipment

Chest tubes and drain systems can be confusing. This ICU #OnePager shows you how they work and demonstrates a 5-step tool for assessing positioning, drainage, tidaling, air leak, and suction. Also demonstrates how to build a three bottle drainage system in case you find yourself managing pnuemothoraces on a desert island (or an airplane).

Current version 1.0 (2020-07-04) Also available in 🇪🇸Spanish (PNG, PDF, PPT)

Acid Base Made Easy

#criticalCare #pulmonary #acidBase #ABG #VBG

Acid base abnormalities are ubiquitous in the ICU, and sometimes multiple can coexist at the same time. This OnePager outlines a stepwise approach and differential diagnosis for each acid base abnormality (RAGES for NAGMA, GOLDMARKeT for AGMA, BLVD PLACE for metabolic acidosis, etc). It also includes those handy formulas & rules so you can figure out if more than acid-base disturbance is present.

Current version 1.4 (originally posted 2020-10-04, updated 2022-06-10)

Weaning from Mechanical Ventilation

#criticalCare #ventilators #weaning #SBT

We talk a lot about how to intubate people, but we don’t say nearly enough about about how to get the tube out. Here is a #OnePager on how to optimize for success and evaluate readiness to wean from mechanical ventilation.

Current version 1.0 (2020-03-24)

Understanding & Treating ARDS

#criticalCare #ventilators #ARDS #proning

Acute Respiratory Distress Syndrome (ARDS) is one of the most serious and challenging conditions we encounter in the ICU. It’s also one of the life threatening complications of COVID-19. Here’s a #onePager that will help you understand ARDS, including its definition, pathophysiology, and the approach I use for treatment. Hint: just remember the Eight P’s: PEEP (lung protective ventilation), Prone positioning, Paralysis (neuromuscular blockade), Prostacyclins (inhaled vasodilators), Peeing (diuresis), Pleural evacuation (thoracentesis), Peripheral oxygenation (ECMO), and Prednisone (corticosteroids).

Current version 1.1 (originally posted 2020-03-30; last updated 2020-10-01) Also available in Spanish 🇪🇸 (JPEG).

Lobar Collapse on CXR

#criticalCare #pulmonary #radiology #CXR

Lobar collapse is common in intubated ICU patients. Here is a an ICU One Pager on identifying which lobe is collapsed using just a CXR. Bonus: Teaches you how to get the most out of the PA and lateral too.

Current version v1.0 (2020-03-19)

Pain, Anxiety, and Delirium

#criticalCare #neurology #pain #anxiety #delirium

One of the most important things we do in critical care is manage pain and anxiety while avoiding delirium. Here’s a #OnePager summary of how I assess, prevent, and treat each of these issues. Handy cheat-sheet for RASS & CAM-ICU scoring too.

Current version v1.1 (2020-03-30)

Swans Made Simple

#criticalCare #cardiology #monitoring #hemodynamics #waveforms #ICUequipment

As Physiology Nerds we love Pulmonary Artery Catheters, but there are lots of tricky details. How can we tell what chamber it is in? How do we accurately measure PAOP? I made this #OnePager to demystify the Swan and show the expected pressures and waveforms encountered sequentially during placement/wedging.

Current version v1.1 (updated 2018-03-24)

Other ICU Resources