Title: Acute on Chronic Liver Failure

Category: Critical Care

Posted: 4/3/2018 by Mike Winters, MBA, MD

Acute on Chronic Liver Failure

Patients with cirrhosis can comprise up to 5% of an ICU population.
Many of these patients will present to the ED, and be admitted to the ICU, for acute on chronic liver failure.
A few management pearls for these patients include:
- Consider albumin in patients with hepatorenal syndrome, large-volume paracentesis (> 5 L), and SBP
- Norepinephrine is the initial vasopressor of choice; target a MAP ≥ 60 mm Hg
- The INR does not accurately reflect bleeding in these patients. Use platelet count and fibrinogen.
- There is no need to correct coagulation abnormalities prior to routine procedures (e.g., central venous catheterization)

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Title: Risk Factors for Peri-Intubation Cardiac Arrest

Category: Critical Care

Posted: 3/20/2018 by Mike Winters, MBA, MD

Peri-Intubation Cardiac Arrest

Endotracheal intubation is a high-risk procedure, especially in the critically ill patient.
The incidence of peri-intubation cardiac arrest ranges from 2% to 5%, and is associated with significant increases in morbidity and mortality.
Authors of a recent retrospective analysis across 64 French ICUs sought to determine risk factors for cardiac arrest during ICU intubation.
Among 1,847 intubations, the main predictors of cardiac arrest during intubation were:
- Pre-intubation arterial hypotension (SBP < 90 mm Hg) (OR 3.4)
- Pre-intubation hypoxemia (OR 3.99)
- Absence of preoxygenation (OR 3.58)
- Obesity (OR 2)
- Age > 75 years of age (OR 2.25)
Take Home Point
- Pay close attention to these risk factors and "resuscitate before you intubate".

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Title: Hyperoxia in the Post-Arrest Patient

Category: Critical Care

Posted: 2/6/2018 by Mike Winters, MBA, MD

Hyperoxia and the Post-Arrest Patient

Current post-arrest guideilnes recommend titrating supplemental O2 to avoid hypoxia and limit exposure to hyperoxia.
Importantly, these recommendations are based primarily on retrospective studies that have used ABG values within the first 24 hours following ROSC.
The latest study to evaluate the impact of hyperoxia following cardiac arrest was just published in Circulation.
This study is a prospective, cohort study that evaluated the association between early hyperoxia and poor neurologic outcome in adults following cardiac arrest. (ABGs were obtained at 1 hour and 6 hours following ROSC)
Of 280 patients, 38% were exposed to early hyperoxia (defined as a PaO2 > 300 mm Hg)
Take Home Points
- Early hyperoxia was found to be an independent predictor of poor neurologic outcome at hospital discharge.
- One hour longer duration of hyperoxia was associated with a 3% increase in the risk of poor neurologic outcome
- SaO2 could not reliably exclude the presence of hyperoxia.

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Title: Septic Cardiomyopathy

Category: Critical Care

Posted: 1/9/2018 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Septic Cardiomyopathy

Cardiac dysfunction is common in patients with sepsis.
Though mulitiple definitions exist, sepsis cardiomyopathy (SCM) is generally defined as an "acute syndrome of cardiac dysfunction that is unrelated to ischemia in patients with sepsis".
Depending on the study, the incidence of SCM ranges anwywhere from 7% to 70%.
Risk factors for SCM include:
- Male
- Younger age
- High lactate at admission
- History of heart failure
The best approach to treating patients with SCM is to maximize your treatment of sepsis.
Dobutamine is no longer routinely recommended for SCM based solely on measurements of ScvO2.

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Title: Sedating the Critically Ill Patient

Category: Critical Care

Posted: 12/12/2017 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Sedating The Critically Ill Patient

Sedating critically ill ED patients can be challenging.
Excessive sedation is associated with a prolonged duration of mechanical ventilation, ICU LOS, and may increase mortality.
Important pearls to consider when managing these patients include:
- Prioritize pain management first - may reduce the need for sedative medications
- When possible, target a calm and interactive patient shortly after intubation - consider adding a atypical antipyschotic with propofol or dexmedetomodine
- Use a validated tool (i.e., RASS) to dose opioids and sedative medications
- Avoid continuous infusions of benzodiazepines

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Title: Mechanical Ventilation in Shock

Category: Critical Care

Posted: 11/14/2017 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Mechanical Ventilation in Shock

Emergency physicians and intensivists routinely resuscitate patients in shock.
For patients who manifest signs of persistent shock (i.e., rising lactate), consider intubation and mechanical ventilation, even in the absence of acute respiratory failure.
The respiratory muscles are avid consumers of oxygen. In fact, up to 50% of available O2 can be used by the respiratory muscles to perform the work of breathing.
Initiation of mechanical ventilation can reduce oxygen consumption and allow oxygen to be shunted to other vital organs.

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Title: Improving CPR Performance

Category: Critical Care

Posted: 10/17/2017 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Improving CPR Performance

High-quality CPR is the cornerstone of successfull resuscitation from cardiac arrest.
In fact, high-quality CPR is considered the most important intervention for achieving ROSC and good neurologic recovery.
Pearls for optimizing CPR performance include:
- Use a team-focused approach
- Avoid leaning and ensure complete recoil of the chest
- Target a chest compression fraction of at least 60%
- Use POCUS, but pay attention to the duration of hands-off time
- Target ETCO2 of > 20 mm Hg

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Title: Post-Arrest Mechanical Ventilation

Category: Critical Care

Posted: 9/19/2017 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Post-Arrest Tidal Volume Setting

Most patients with ROSC from out-of-hospital cardiac arrest undergo endotracheal intubation and mechanical ventilation.
Optimal management of mechanical ventilation for the post-arrest patient is currently not well defined.
A recent retrospective cohort study sought to determine if a lower tidal volume (Vt) was associated with improved neurocognitive outcome at hospital discharge.
Of 256 patients included in the study, investigators found:
- 38% were ventilated with Vt > 8 ml/kg predicted body weight
- Lower Vt was significantly associated with favorable neurocognitive outcome, decreased duration of mechanical ventilation, and decreased ICU length of stay
Take Home Pearl: Pay attention to Vt in the post-arrest patient.

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Title: Hyponatremic Encephalopathy

Category: Critical Care

Posted: 8/22/2017 by Mike Winters, MBA, MD

Hyponatremic Encephalopathy

Hyponatremic encephalopathy is a true emergency and due to hypoosmolar-induced cerebral edema.
In contrast to the asymptomatic patient with hyponatremia, treatment of hyponatremic encephalopathy is determined by symptoms and not the duration of hyponatremia.
Clinical manifestations include nausea, vomiting, headache, confusion, seizures, respiratory failure, and coma.
Hypertonic saliine is the treatment of choice
- Administer 2 ml/kg 3% hypertonic saline (100 ml in many cases)
- This will typically raise serum sodium 2 mEq/L
- In most cases, a 4-6 mEq/L rise will reverse neurologic symptoms

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Title: Improving Resuscitation Performance

Category: Critical Care

Posted: 7/25/2017 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Improving Resuscitation Performance

Resuscitating the critically ill patient can often be quite stressful.
Stress has been shown to decrease the quality and effectiveness of decisions, decrease the amount of information a person can process, and lead to short-term memory deficits.
Recently, there has been emphasis on the use of performance-enhancing psychological skills (PEPS) to allow providers to think clearly, maintain situational awareness, recall important information, and perform skills efficiently.
A recent article highlights 4 key elements of an EM model for PEPS that can be used to improve performance in resuscitations.
- Breathe - consider tactical breathing
- Talk - positive instructional or motivational self-talk
- See - visualize the steps of a procedure before actually performing it
- Focus - use a trigger word as a prompt to shift attention to a prioritized task

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Title: Ventilation During Cardiopulmonary Resuscitation

Category: Critical Care

Keywords: CPR, ventilation, respiratory rate, PaCO2 (PubMed Search)

Posted: 6/27/2017 by Mike Winters, MBA, MD

Ventilation During Cardiopulmonary Resuscitation

Cardiopulmonary resuscitations are often highly stressful and chaotic situations. As a result, it is no surprise that ventilation rates can be as high as 60 breaths per minute.
Hyperventilation during cardiopulmonary resuscitation can increase intrathoracic pressure, impair venous return, decrease coronary perfusion pressure, and ultimately decrease survival.
It is imperative that the team leader pay close attention to ventilation and ensure that approximately 8 to 10 breaths per minute are delivered.
Once ROSC is achieved, the respiratory rate should be adjusted to maintain a PaCO2 between 40 and 45 mm Hg.

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Title: Don't Forget that Second Dose!

Category: Critical Care

Posted: 5/23/2017 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Antibiotics in Sepsis

Currently international guidelines for the management of sepsis and septic shock recommend antibiotic administration within 1 hour of recognition.
With the persistent problem of ED boarding, many patients with sepsis and septic shock remain in the ED long after the initial dose of broad-spectrum antibiotics.
A recent single center, retrospective cohort study demonstrated that 1 out of 3 patients with sepsis or septic shock experienced major delays in the time to the second dose of antibiotics. In fact, over 70% of patients who were given an initial antibiotic with a 6-hr recommended dosing interval experienced major delays.
Inpatient boarding in the ED was found to be an independent risk factor for major delays.
Take Home Point: Don't forget to write for additional doses of antibiotics in your boarding patients with sepsis.

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Title: Ventilator Settings in the Post-Arrest Patient

Category: Critical Care

Posted: 4/25/2017 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Ventilator Settings for the Post-Arrest Patient

The majority of patients with ROSC from OHCA require intubation and mechanical ventilation.
Correctly managing the ventilator in the post-arrest patient is critical for improving outcomes.
As patients are at high risk for ARDS, use lung-protective ventilation with tidal volumes between 6 to 8 ml/kg of ideal body weight and PEEP of 5 to 8 cm H2O.
There is a U-shaped relationship between neurologic outcomes and both PaO2 and PaCO2.
- Target normoxia (SpO2 94% to 96%) and avoid hyperoxia and hypoxia.
- Target normocapnia (PaCO2 40 to 50 mm Hg) and avoid hypercapnia and hypocapnia.
Use an analgosedation approach with short-acting analgesics and sedatives, such as fentanyl and propofol.

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Title: Ketamine is Not Without Risk

Category: Critical Care

Posted: 3/28/2017 by Mike Winters, MBA, MD (Updated: 3/4/2026)

DSI, Ketamine, and Apnea

In recent years, delayed sequence intubation (DSI) with ketamine has been used in select patients to maximize preoxygenation and dinitrogenation.
Importantly, DSI is not well studied. In the only prospective trial of DSI, patients received approximately 1.4 mg/kg of ketamine.
Driver, et al. report the abrupt onset of apnea in a patient who received a much lower dose of ketamine (25 mg) for DSI.
Take Home Point: If DSI is a part of your preoxygenation armamentarium, apnea can occur even at low doses of ketamine. Stand at the patient's bedside and be ready to immediately intubate the patient.

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Title: Preoxygenation in the Critically Ill

Category: Critical Care

Posted: 3/7/2017 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Preoxygenation in Critically Ill Patients

Achieving adequate preoxygenation and denitrogenation prior to intubating critically ill patients can be challenging.
Critically ill patients have physiologic alterations (i.e., derangements in oxygen consumption, anemia, reduced cardiac output, air space disease) that can markedly reduce safe apnea time.
For patients with significant air space disease and shunt physiology, noninvasive ventilation (NIV) can decrease shunt fraction, increase functional residual capacity, improve PaO2, and lengthen safe apnea time.
Importantly, NIV should be used for at least 3 minutes to achieve improvements in alveolar recruitment.
It is also important to remove NIV just prior to larygnoscopy, as alveoli will begin to derecruit when NIV is removed.

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Title: Sepsis Mimics

Category: Critical Care

Posted: 2/14/2017 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Sepsis Mimics

Emergency physicians are well versed in the resuscitation of patients with sepsis and septic shock.
With the recent publication of the 2016 SSC Guidelines and the emphasis in meeting various quality measures, sepsis is routinely included in the differential diagnosis of critically ill patients.
Notwithstanding, it is important to consider other disease states that can present similarly to sepsis or septic shock. Some of these include:
- Anaphylaxis
- Adrenal insufficiency
- DKA
- Thyroid storm
- Toxic ingestion or withdrawal

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Title: Epinephrine in Anaphylaxis

Category: Critical Care

Posted: 1/24/2017 by Mike Winters, MBA, MD

Epinephrine in Anaphylaxis

Delayed administration of epinephrine for patients witih anaphylaxis is associated with increased morbidity and mortality.
Providers are often hesitant to administered epinephrine to older patients with anaphylaxis for fear of precipitating an adverse cardiovascular event.
A recent retrospective study of almost 500 patients demonstrated that older patients were significantly less likely to receive epinephrine, despite meeting the definition for anaphylaxis.
Furthermore, cardiovascular complications occurred in just 9 patients, 6 of which received an excessive dose via the IV route.
Take Home Point: There are no absolute contraindications (including age) for epinephrine in patients with anaphylaxis. Give the initial dose IM into the anterolateral thigh.

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Title: Post-Arrest PaCO2

Category: Critical Care

Posted: 1/3/2017 by Mike Winters, MBA, MD

PaCO2 and the Post-Arrest Patient

Alterations in PaCO2 are common during the post-arrest period and have been associated with worse patient centered outcomes.
Hypercarbia can dilate cerebral vessels, increase cerebral blood flow, and may increase intracranial pressure.
Conversely, hypocarbia can constrict cerebral vessels and may reduce cerebral blood flow.
Though the current evidence is primarily limited to observational trials, a recent meta-analysis found that "normocarbia" was associated with improved hospital survival and neurologic outcome.
Take Home: Adjust mechanical ventilation to target normocarbia (PaCO2 or ETCO2) in the post-arrest patient.

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Title: Obesity and Mechanical Ventilation

Category: Critical Care

Posted: 12/13/2016 by Mike Winters, MBA, MD

Mechanical Ventilation in the Obese Patient

Obesity can result in decreased lung volumes, decreased lung and chest wall compliance, and increased work of breathing.
Unfortunately, there is very little literature to guide the emergency physician on mechanical ventilation in obese patients.
A recent study of intubated ED patients by Goyal, et al found that over 1 in 5 patients were ventilated with potentially injurious tidal volumes.
Importantly, obesity increased the odds of inappropriate ventilator settings.
In the intubated obese patient, be sure to set tidal volume based on ideal body weight and consider starting with a higher PEEP setting (i.e., 10 to 15 cm H2O).

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Title: Cardiac Arrest - What Matters?

Category: Critical Care

Posted: 11/22/2016 by Mike Winters, MBA, MD (Updated: 3/4/2026)

What Matters in Cardiac Arrest?

Approximately 500,000 adults suffer sudden cardiac arrest each year in the United States.
The most important components of cardiac arrest care that have been shown to improve outcomes are:
1. High-quality CPR with little to no interruptions
2. Defibrillation for ventricular arrhythmias
3. Optimal post-arrest care
  - Target an SpO2 of 94-98%
  - Target an ETCO2 of 35-40 mm Hg (PaCO2 of 40-45 mm Hg)
  - Targeted temperature management
  - Early cardiac catheterization

61-80 of 354 results by Mike Winters

Title: Acute on Chronic Liver Failure

Title: Risk Factors for Peri-Intubation Cardiac Arrest

Title: Hyperoxia in the Post-Arrest Patient

Title: Septic Cardiomyopathy

Title: Sedating the Critically Ill Patient

Title: Mechanical Ventilation in Shock

Title: Improving CPR Performance

Title: Post-Arrest Mechanical Ventilation

Title: Hyponatremic Encephalopathy

Title: Improving Resuscitation Performance

Title: Ventilation During Cardiopulmonary Resuscitation

Title: Don't Forget that Second Dose!

Title: Ventilator Settings in the Post-Arrest Patient

Title: Ketamine is Not Without Risk

Title: Preoxygenation in the Critically Ill

Title: Sepsis Mimics

Title: Epinephrine in Anaphylaxis

Title: Post-Arrest PaCO2

Title: Obesity and Mechanical Ventilation

Title: Cardiac Arrest - What Matters?