EMCrit Podcast

Exploring the challenges of intubating neurologically critical patients with elevated intracranial pressure, highlighting the importance of precise technique. Strategies for preventing adverse outcomes in traumatic brain injury, aortic dissection, and subarachnoid bleed. Utilizing fentanyl, esmolol, nicardipine, and hypertonic saline to manage blood pressure spikes and intracranial pressure. Benefits of propofol and ketamine mix for stable neurocritical care intubation, emphasizing hemodynamic stability and cerebral metabolic rate reduction.

We now have way too many treatment options for sub-massive and massive pulmonary embolism (PE) patients who aren't coding in front of you. How do you decide which one is right for your patient? To help answer this question, I am joined today by Oren Friedman, pulmonary critical care doc and one of the members of the Cornell PEAC team. Cornell Pulmonary Embolism (PE) Advanced Care Team (PEAC), aka the CLOT Team Oren Friedman MD, Pulm Crit Care; James Horowitz MD, Cardiology; Arash Salemi MD, Cardiac Surgery; Akhilesh Sista MD, Interventional Radiology You can shoot the team an email: peadvancedcare at gmail dot com Who Should We Treat? Wood 2002 PE Mortality Curve 30% normotensive patients have RVD; 10% progressed to shock; 5% in hospital mortality[cite]10859287[/cite] The Better Risk Categories for Pulmonary Embolism Well and Stable Sub-Massive High-Risk Sub-Massive Massive PEITHO Trial NEJM 2014;370(15):1402 Full dose tenecteplase with concurrent heparin Death or hemodynamic decompensation occurred in 2.6% of the tenecteplase group as compared with 5.6% of the placebo group Extracranial bleeding occurred in 32 patients (6.3%) in the tenecteplase group and 6 patients (1.2%) in the placebo group (P0.06 ?g/L or troponin T >0.01 ?g/L.  These may be relatively inclusive thresholds. Not all placebo patients developing hemodynamic collapse received subsequent thrombolysis; likewise, almost half of those who received open-label thrombolysis had no hemodynamic collapse. Half the deaths in the placebo arm were “sudden unexplained” or “other”, compared with bleeding or stroke complications in the thromboysis arm. TOPCOAT Trial Jeff Kline's trial was stopped midway through due to an institution change. Complicated primary endpoint with promising, but unusable results [cite]24484241[/cite] For the scoop on this one see the Bottom Line Review post on TOPCOAT MOPETT Trial Half-dose alteplase led to a marked reduction in pulmonary hypertension without sig. complications Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT trial). (J Cardiol 2013; 111: 273) See this prior EMCrit Wee as well on MOPPETT Update: This meta-analysis states that the half-dose may be appropriate, effective, and safe [cite source='pubmed']24412030[/cite] Meta-Analysis Chatterjee et al. have the most current meta-analysis on this topic (JAMA. 2014;311(23):2414-2421) See the Bottom Line Review post on this study Nakamura just published another MA this week; see Rory Spiegel's take on the two here Is it just in the Oldies? Markedly lower risk in

BVMs are ridiculously crappy and downright dangerous. The solution? the Oxylator

Exploring the significance of early adopters in embracing new technologies in medicine, emphasizing the importance of building a strong belief structure before implementing innovations. Discussing the challenges and risks of being an early adopter in the medical field and the importance of informed decision-making and continuous learning in navigating early adoption.

In this episode, I speak with Niklas Nielsen on his thoughts on the TTM trial.

I told you today we would have a bit of discussion on Rob Mac Sweeney's FOAM. Well here it is...

Should we err towards errors of commission or omission?

Proning is one of the only evidence-based techniques to affect the mortality of ARDS patients. I've been wanting to do an episode on proning for a while.

I talk with a member of the surviving sepsis campaign steering committee re: ProCESS