Title: Pay Attention to the Diastolic Blood Pressure

Category: Critical Care

Posted: 8/9/2022 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Diastolic Blood Pressure

The diastolic blood pressure (DBP) is determined by vascular tone and remains relativley constant throughout the arterial system.
A low DBP (< 50 mm Hg) suggests vasodilation and may be associated with an increased risk of myocardial ischemia and left ventricular dysfunction.
In a recent trial, Ospina-Tascon and colleagues described the diastolic shock index (heart rate/DBP) and found that a DSI > 2.2 was associated with higher mortality in patients with septic shock.
Take Home Point: pay attention to the DBP and, when low, consider initiation of vasopressors concomitant with fluid resuscitation.

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Title: Vasopressors in the Critically Ill

Category: Critical Care

Posted: 6/14/2022 by Mike Winters, MBA, MD

Vasopressor Tips in the Critically Ill

Critically ill patients often require the administration of vasopressors to maintain adequate organ perfusion.
A few tips to consider when administering vasopressors include:
- Titrate to mean arterial blood pressure (MAP) or diastolic blood pressure goals. Systolic blood pressure (SBP) is not a key driver of perfusion pressure.
- As vasopressors also result in venoconstriction and can increase venous return, early initation may limit the need for overly aggressive fluid resuscitation.
- Vasopressors can be safely administered through an appropriately placed peripheral venous catheter.
- There is no maximal dose of vasopressors.
- Consider vasopressors with a different mechanism of action in patients with persistent shock refractory to the initial vasopressor agent.

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Title: Low-Tidal Volume Ventilation in the ED - Does it Make a Difference?

Category: Critical Care

Posted: 4/19/2022 by Mike Winters, MBA, MD (Updated: 3/4/2026)

ED Low-Tidal Volume Ventilation

Low-tidal volume ventilation (LTVV) reduces mortality in patients with ARDS and may reduce mortality in patients without ARDS.
Recent literature has highlighted the importance of initial ED ventilator settings, as these often persist for many hours after ICU admission.
But..does the use of LTVV in the ED really make a difference?
A recent systematic review and meta-analysis sought to evaluate the use of LTVV in the ED and the impact upon clinical outcomes.
In short, the use of LTVV in the ED was associated with an increase in the use of LTVV in the ICU, decreased occurrence of ARDS after admission, shorter ICU and hospital lengths of stay, decreased duration of mechanical ventilation, and decreased mortality.
Take Home Point: The use of LTVV in the ED makes a difference!

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Title: Hyperglycemic Hyperosmolar State

Category: Critical Care

Posted: 2/22/2022 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Hyperglycemic Hyperosmolar State (HHS)

Though less common, HHS has a mortality rate that is 10x greater than DKA.
The hallmark features of HHS include severe hyperglycemia (> 600 mg/dL), hyperosmolality (> 320 mOsm/kg), minimal to no ketosis, and severe dehydration.
Though the management of HHS is similar to DKA and includes fluid resuscitation, correction of hyperglycemia, and correction of electrolyte abnormalities, it is important to also monitor serum osmolality.
Too rapid correction of serum osmolality can cause cerebral edema and worsen patient outcomes.
Current recommendations are to monitor serum osmolality every 1-2 hours with a correction of no more than 3 mOsm/kg/hr.

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Title: Bougie or Endotracheal Tube with Stylet for First Attempt?

Category: Critical Care

Posted: 12/28/2021 by Mike Winters, MBA, MD

The BOUGIE Trial

More than 1 million patients undergo endotracheal intubation each year in the US.
Up to 20% of intubations fail on the first attempt, thereby increasing the risk of adverse outcome.
Over the past several years, many have become comfortable using the bougie as a rescue device when the first attempt at intubation fails with an endotracheal tube with stylet.
In contrast to its use as a rescue device, should the bougie be used during the first attempt rather than an endotracheal tube with a malleable stylet?
The BOUGIE Trial compared the effect of using the bougie to an endotracheal tube with stylet on first attempt success in critically ill patients.
The trial enrolled 1106 patients in 7 EDs and 8 ICUs at 11 hospitals.
The primary outcome of first pass success was not statistically different between those randomized to bougie and those randomized to endotracheal tube with stylet for the first attempt at intubation..
Though the trial did not find a statistical difference in first pass success rates, the bougie remains an important device in our management of the critically ill airway.

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Title: The Critically Ill Asthmatic Patient

Category: Critical Care

Posted: 11/2/2021 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Initial Mechanical Ventilation Settings for the Intubated Asthmatic

Approximately 2% of adult patients who present with an acute asthma exacerbation will require intubation and mechanical ventilation.
It is critical to provide the intubated asthmatic with sufficient time for exhalation.
Initial recommended settings for mechanical ventilation include:
- Tidal volume: 6-8 ml/kg ideal body weight
- Respiratory rate: 6-10 breaths per minute
- PEEP: 0-5 cm H2O
- Inspiratory flow rate: 80-120 L/min
Permissive hypercapnea is tolerated to a pH of approximately 7.15

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Title: Intermediate-High Risk PE Patients

Category: Critical Care

Posted: 9/7/2021 by Mike Winters, MBA, MD

Management of Intermediate-High Risk PE Patients

Though there are varying definitions, intermediate-high risk patients with a PE are generally defined as those who are hemodynamically stable, have radiographic or laboratory evidence of right heart strain, and an elevated PE risk score.
A few key management pearls include:
- Be judicious with IVFs to avoid worsening septal shift and fruther decreases in LV cardiac output.
- Consider dobutamine for severe RV dysfunction.
- Administer norepinephrine, if needed, to achieve a MAP of 65 mm Hg.
- Avoid initiation of positive pressure ventilation, if possible.
- If intubation is needed for clinical deterioriation avoid propofol for RSI. Propofol has been associated with increased mortality in this patient population.

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Title: HLH in the ED

Category: Critical Care

Posted: 7/20/2021 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Hemophagocytic Lymphohistiocytosis (HLH)

HLH is a hematologic disorder that results from overactivation of the immune response (macrophages and cytotoxic T cells).
HLH is often underrecognized and has a mortality that can be as high as 75%.
Secondary HLH is most commonly associated with infection (sepsis), malignancy (lymphoma), and autoimmune disorders (SLE, RA).
Hallmark features of HLH include fever, splenomegaly, hepatomegaly, cytopenias, coagulopathy, elevated ferritin, elevated triglycerides, and decreased fibrinogen levels.
ED resuscitation of patients with suspected HLH includes Hematology consultation, treatment of the underlying disorder (infection), and potentially corticosteroids and chemotherapeutic agents.

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Title: Refractory Anaphylaxis

Category: Critical Care

Posted: 5/25/2021 by Mike Winters, MBA, MD

Refractory Anaphylaxis

Refractory anaphylaxis is defined as anaphylaxis that does not respond to at least 2 doses of 300 mcg of epinephrine given IM into the anterolateral thigh.
Refractory anaphylaxis can be due to several factors including patient comorbidities, delayed diagnosis, delayed epinephrine administration, or concomitant beta-blocker or ACE-inhibitor medication use.
Consider the following treatments in patients with refractory anaphylaxis, persistent hypotension, and shock:
- Aggressive IVF resuscitation - patients may need up to 7L of IVFs
- Epinephrine infusion (1-10 mcg/min) to target a MAP of 65 mm Hg
- Glucagon (1-5 mg via slow IV push) for those taking a beta-blocker and who fail to respond to epinephrine
- Norepinephrine, vasopressin, angiotensin II, methylene blue, or dobutamine can be administered with epinephrine for persistent hypotension.
- VA-ECMO - though there is no prospective evidence on the use of ECMO in anaphylaxis.

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Title: Simple Interventions to Improve LPV Compliance

Category: Critical Care

Posted: 3/30/2021 by Mike Winters, MBA, MD

Improving Compliance with Lung-Protective Ventilation

Approximately 250,000 ED patients are intubated and receive mechanical ventilation each year in the United States.
While emergency physicians understand the importance of providing lung-protective ventilation, current studies demonstrate that more than 40% of ED patients are placed on initial tidal volumes > 8 ml/kg of predicted body weight (PBW).
In many cases, this may be due to the inaccurate estimation of patient height when determining PBW.
In a recent single-center study, Tallman and colleagues evaluated a quality improvement intiative, whereby respiratory therapists were provided with a tape measure and an EHR BPA that reminded them to measure the patient's height for PBW.
In this study, these simple, low-cost interventions significantly increased compliance with lung-protective ventilation.
Take Home Pearl: Be sure to measure your intubated patient to accurately determine PBW and set the correct tidal volume.

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Title: Mechanical Ventilation for the Critically Ill COPD Patient

Category: Critical Care

Posted: 2/2/2021 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Mechanical Ventilation in COPD

Mechanical ventilation of the patient with obstructive lung disease can be challenging, primarily due to the presence of dynamic hyperinflation.
In the initial phase of ventilation, it is important to prevent complications of hyperinflation and not to target normalization of blood gas values.
Recommended initial ventilator settings include:
- Mode: Volume assist-control
- Inspiratory flow waveform: square
- Tidal volume: 6-8 ml/kg PBW
- RR: 12 bpm
- Inspiratory flow: 60-90 L/min
The effect of PEEP is variable with each patient. When titrating PEEP, be sure to frequently measure plateau pressure and discontinue titration should Pplat increase.

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Title: PEEP in the Intubated Obese Patient

Category: Critical Care

Posted: 12/8/2020 by Mike Winters, MBA, MD

PEEP in the Intubated Obese Patient

Obesity has numerous adverse effects on the respiratory system, most notably a reduction in lung volumes.
The reduction in lung volumes (i.e., FRC) often result in airway closure and atelectasis.
The application of PEEP in the mechanically ventilated patient helps maintain alveolar patency by preventing derecruitment.
Importantly, the typical initial PEEP setting of 5 cm H2O is insufficient for many ventilated obese patients.
Pearl: In the ventilated obese patient start with an initial PEEP of 10-15 cm H2O.

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Title: Blood Pressure in Acute Ischemic Stroke

Category: Critical Care

Posted: 10/13/2020 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Blood Pressure Management in Acute Ischemic Stroke

Blood pressure (BP) is elevated in many patients who present to the ED with an acute ischemic stroke (AIS).
Severe elevations in BP are associated with hemorrhagic transformation, as well as cardiac and renal complications.
As such, it is important to know the various BP goals for patients with an AIS.
- Permissive hypertension with a BP less than or equal 220/120 mm Hg is recommended for patients not receiving IV-tPA or endovascular therapy.
- BP should be lowered to less than or equal to 180/105 mm Hg for patients who have received IV-tPA.
- BP goals for patients who have received endovascular therapy remain controversial and should be individualized based on the degree of recanalization.

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Title: Ketamine in the Critically Ill

Category: Critical Care

Posted: 8/25/2020 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Ketamine In the Critically Ill Patient

Ketamine has become a popular agent in the ED for both RSI and procedural sedation.
Given the sedative, analgesic, dissociative, antidepressant, and anti-inflammatory properties, ketamine has also been used in a number of other critical illness conditions including:
- Acute pain management
- Status asthmaticus
- Alcohol withdrawal syndrome
- Status epilepticus
- Acute agitated delirium
The authors of a recent review in Critical Care Medicine found that the evidence supporting the use of ketamine in the critically ill is most robust for adjunctive analgesia in the intubated patient. Surprisingly, the data is very limited to support the use of ketamine in these other conditions.
Pearl: ketamine does have a myocardial depressant effect, which can be unmasked in states of catecholamine depletion and result in hypotension and bradycadia.

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Title: Analgesic & Sedative Dosing in the Critically Ill Obese Patient

Category: Critical Care

Posted: 6/16/2020 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Analgesics & Sedatives in the Critically Ill Obese Patient

Analgesic and sedative medications are frequently administered to critically ill patients.
Weight-based dosing regimens for these medications can lead to significant over-, or under-, dosing in the critically ill obese patient (BMI > 40 kg/m²).
In order to avoid harm, it is important to know when to use actual body weight (ABW), ideal body weight (IBW), or adjusted body weight in weight-based dosing regimens.
Recommendations for weight-based dosing regimens for commonly used analgesic and sedative medications include:
- Opioids: use IBW or adjusted body weight
- Ketamine: use IBW or adjusted body weight
- Propofol: use IBW or adjusted body weight
- Etomidate: use adjusted body weight or ABW
- Midazolam: use IBW or adjusted body weight

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Title: Vitamin C for Septic Shock?

Category: Critical Care

Posted: 4/28/2020 by Mike Winters, MBA, MD

Vitamin C for Septic Shock?

In 2017, a single center before-and-after study demonstrated benefit for patients with sepsis who received vitamin C, hydrocortisone, and high-dose thiamine.
At present, there are more than 30 trials evaluating the use of vitamin C in sepsis.
The VITAMINS Trial was recently published and evaluated shock resolution in patients with septic shock who received vitamin C, hydrocortisone, and high-dose thiamine compared to those that received only hydrocortisone.
In this randomized controlled trial of 211 ICU patients, the authors found no difference in the primary outcome of time alive and free of vasopressors at 7 days between the two groups.
There was also no difference in the secondary outcomes of hospital, 28-day, and 90-day all-cause mortality.
Though we still await the results of ongoing trials, the VITAMINS Trial and the recent CITRIS-ALI Trial have not demonstrated benefit of vitamin C for select patient populations with sepsis.

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Title: Mechanical Ventilation of the Patient with Acute Ischemic Stroke

Category: Critical Care

Posted: 1/21/2020 by Mike Winters, MBA, MD

Mechanical Ventilation Pearls for Acute Ischemic Stroke

Patients with an acute ischemic stroke (AIS) may require intubation for various reasons.
Two main goals of mechanical ventilation in patients with an AIS are to maintain appropriate oxygen levels and tight control of PaCO2.
In terms of oxygenation:
- Target normoxia
- Administer O2 if the SpO2 is < 94%
- Supplemental O2 is not recommended in non-hypoxic patients
In terms of CO2:
- Target normocapnia
- Hypercapnia increases the risk of intracranial hypertension
- Hypocapnia can worsen cerebral perfusion

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Title: Interventions Shown to Reduce Mortality in RCTs

Category: Critical Care

Posted: 12/3/2019 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Interventions Shown to Reduce Mortality in RCTs

Santacruz and colleagues recently performed a systematic review to determine which multicenter RCTs in critically ill patients have shown that an intervention was associated with a reduction in mortality.
Approximately 13% of the 212 trials included in this review reported a statistically significant reduction in mortality. Unfortunately, many of the interventions were not associated with reduced mortality in subsequent studies.
Interventions consistently shown to reduce mortality in multicenter RCTs in critically ill patients were limited tidal volume in patients with ARDS, noninvasive ventilation in acute hypercapnic respiratory failure, and noninvasive ventilation following extubation in complex cases.
Corticosteroids in septic shock, selective digestive decontamination, and prone positioning in ARDS remain controversial.

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Title: The Critically Ill Geriatric Patient with Sepsis

Category: Critical Care

Posted: 10/15/2019 by Mike Winters, MBA, MD (Updated: 3/4/2026)

The Critically Ill Geriatric Patient with Sepsis

Due to the age-related physiologic change of immunosenescence, geriatric patients have an increased susceptibility to infection, a decreased ability to mount a response to infection, and an increased likelihood of atypical presentations.
Atypical presentations of sepsis in the geriatric patient include confusion, decreased functional status, generalized weakness, and failure to thrive.
In fact, up to 33% of geriatric patients with bacteremia will be afebrile upon presentation.
Consider sepsis in the differential diagnosis of geriatric patients with these nonspecific complaints.

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Title: Critical Care Pearls for AIS

Category: Critical Care

Posted: 8/27/2019 by Mike Winters, MBA, MD

Critical Care Management of AIS

In addition to reperfusion therapy, the critical care management of patients with an acute ischemic stroke also includes airway and ventilation management, hemodynamic management, glucose control, anticoagulation management, and surgery in select cases.
Consider the following management pearls:
- Mechanical ventilation
  - Target SpO2 > 94% (avoid supplemental oxygen for non-hypoxemic patients)
  - Target normocarbia (PaCO2 35-45 mmHg)
- Hemodynamics
  - Target euvolemia with isotonic saline
  - Target BP < 185/110 mmHg for 24 hrs after tPA
  - Target BP < 220/120 mmHg if tPA ineligible
  - Target SBP < 160 mmHg after endovascular therapy
- Glucose
  - Target serum glucose 140-180 mg/dL

21-40 of 354 results by Mike Winters

Title: Pay Attention to the Diastolic Blood Pressure

Title: Vasopressors in the Critically Ill

Title: Low-Tidal Volume Ventilation in the ED - Does it Make a Difference?

Title: Hyperglycemic Hyperosmolar State

Title: Bougie or Endotracheal Tube with Stylet for First Attempt?

Title: The Critically Ill Asthmatic Patient

Title: Intermediate-High Risk PE Patients

Title: HLH in the ED

Title: Refractory Anaphylaxis

Title: Simple Interventions to Improve LPV Compliance

Title: Mechanical Ventilation for the Critically Ill COPD Patient

Title: PEEP in the Intubated Obese Patient

Title: Blood Pressure in Acute Ischemic Stroke

Title: Ketamine in the Critically Ill

Title: Analgesic & Sedative Dosing in the Critically Ill Obese Patient

Title: Vitamin C for Septic Shock?

Title: Mechanical Ventilation of the Patient with Acute Ischemic Stroke

Title: Interventions Shown to Reduce Mortality in RCTs

Title: The Critically Ill Geriatric Patient with Sepsis

Title: Critical Care Pearls for AIS