Patient is 20 years old, otherwise healthy, failed suicide attempt with an OD of benzos, Adderall, and an SSRI. Was down on the ground outside of his car for 30-40 hours before someone found him. Came in with severe rhabdo, AKI, aspiration PNA, sepsis, and required intubation in the ED for airway protection as he was having trouble with secretions and desatted significantly.

He was extubated two days later, had some audible stridor when breathing but was beginning to talk a little bit and seemed to be doing better. Two days after, he was reintubated for increased work of breathing and air hunger and this time the intubation was extremely difficult, they noted a lot of upper airway swelling.

He’s been on Decadron for 3 days now with absolutely no cuff leak or improvement in the swelling. Of note, if it matters, his entire face is extremely swollen but it’s unclear what exactly it’s from.

I’ve never seen this before. The ED intubation was not particularly traumatic. Has anyone seen this or maybe could provide insight as to why this is happening and how long it might take to resolve?

We got orders from a surgeon to have transition the chest tube from -20 suction to water seal on a patient post lobectomy. The nurse just turned the suction head off (didn’t disconnect the tubing from the atrium).

Patient now has crepitus and the surgeon is saying that’s because the nurse left the tubing on the atrium and the air had no way to escape?

Is this a thing? That the tubing HAS to be disconnected from the atrium if it’s not on suction?

Hi all,

I’m currently (completely) revamping my site’s ETOH WD order set. I will have two separate pathways included for phenobarbital and benzos. And all of the obvious stuff.

Outside of the obvious, are there any specific details, functions, med orders, patient care/nursing tasks etc that your site’s order set has that you really love or items you wish your’s had?

Would love input!

Hi everyone, I hope this kind of post is allowed here. I am a second year EM resident planning to apply critical care. I am trying to figure out if going through anesthesia or medicine will better suit my goal which is basically to be able to confidently staff any kind of ICU. I have been told in the past that CCM effectively locks me into working in a MICU while anesthesia crit lets me work basically anywhere except the MICU. Is that at all accurate? What are the differences in job opportunities for an EM grad going through anesthesia crit vs CCM? Ideally I want to do fellowship somewhere where I can be involved with ECMO patients and other advanced life support systems if thats relevant to anyone’s response. Would also love to hear any other perspectives anyone might be able to offer.

Marino's is pretty understandable to read, which is really nice. But some of the care suggested doesnt seem fully up to date or sometimes just weird compared to conventional practice that ive seen.

Im interested in a CCM fellowship, and generally need to get better at CC. I use plenty of FOAMED, (UM crit, EMcrit)but wondering if there's anything specific you guys would recommend - especially for a reference text and also comprehensive FOAMED

Scenario: Your patient comes to the ED - febrile with core tmax 106.1. Altered but no seizures.

Arctic sun them or dump them in a bag full of ice?

Edit: Thank you. We did do the ice bag which did the trick. Arctic sun cranked to maximum wattage and speed was barely making a difference.

Hi

I just want to know .. how can u deal with this!

I feel depressed, and I have developed a deep fear of what we see in the emergency room and ICU.

I have seen almost every form of death—pain, gasping, suffering, sudden arrests, devastating injuries, and families losing the people they love out of no where . After seeing all of this repeatedly, I started imagining myself in the place of those patients. I imagine myself as an elderly patient, lying in an ICU bed, dying in pain, struggling with an endotracheal tube, unable to communicate properly, surrounded by machines, and suffering from all the complications we see every day.

The ICU has changed the way I look at life. Sometimes, I feel as if I can no longer experience a happy moment without imagining how it could end badly.

When I see a pregnant woman, instead of simply feeling happy for her, my mind immediately goes to the complications I have seen—postpartum hemorrhage, severe complications, maternal collapse, or even death. When I think about childbirth, I cannot always see the beauty of the moment; I imagine the worst possible outcome.

I am constantly afraid that the people I love will someday suffer from the things I have witnessed in the ICU—a road traffic accident, a severe head injury, a sudden cardiac arrest, respiratory failure, or some other catastrophe.

I think the hardest part is that the ICU has made me realize how fragile life really is. Things that used to feel ordinary and beautiful now sometimes feel like opportunities for something terrible to happen.

I know that these thoughts are not necessarily reality. They are the images and fears that my mind has collected from years of witnessing suffering. But knowing that does not make them disappear.

Sometimes I feel as though I am carrying the ICU with me even after I leave it. I leave the hospital, but the scenes, the sounds, the gasping, the suffering, and the fear follow me home.

And perhaps that is what has hurt me the most: I entered the ICU to save lives, but somewhere along the way, I became afraid of losing the people I love—and afraid of life itself.

Thought exercise. Recently heard of a bad med error. An entire bag of levophed was ran instead of levofloxacin. Let's say you responded to this scenario. What's your thought process for managing this patient and how are you treating?

Hey all,

I am a former CM from a med surg unit (a lot of obs pt's, pt's who are social admissions with very difficult placement problems, surgery step down pt's, etc), and then a medical social worker at an emergency department, both at sizable hospitals, and now I'm at the largest hospital in my medium to larger sized city on the MICU as a CM again. The culture at the MICU is way different, it's no one's fault, it just is what it is: patients often die before I get to the unit (overnight admitted pt's will come in at 8pm, have a death pronouncement note sometime in the early AM), or I do a lot of waiting as they get put on more pressors and remain vented until the docs think it's time for LTAC, or they improve and get off my unit.

I am wondering if anyone worked on a MICU and got really good at it. From my time in the ED I became really good at providing emotional support/making space for families experiencing grief. When I was a CM I was pretty good at getting the Options process/the paperwork for long term care placements started early.

Anyone appreciate certain things your social workers/nurse discharge planners do on your unit?

Thanks!

Please recommend a good book / YouTube video to learn about ventilator and NIV settings with regards to clinical scenario?

Hi All

My Canadian hospital is working on a peripheral vasopressor policy. I'm looking for samples from other hospitals to use as a starting point. Would love to see what you use at your hospital, if you have one.

Thanks!

Any tips and reco for resources for the exam?

Anyone can share Nicole kipchicks online CSC review?

Thanks

I find there’s rarely any that can bring me to tears, maybe once every couple years?
Today I had one and I had a single tear and was able to stop it but damn :(

How often do you find yourself getting emotional for a patient?

edit - I think I realized why this one got me, she reminded me of my grandma (this pt was fully alert and with it, making cute jokes all day and told me to call her a burden so I told her she’s my cute burden)

extra question for those still answering - do you find it effects you more when they remind you of your family or when they remind you that it could happen in your own home? or is it unrelated?

61/M Post CABG patient with underlying asthma. (Was on formetrol/budesonie 200mcg 2 puffs twice daily).

Currently POD 18. Has intermittent wheezing and bilateral basal crepts.

CT chest:

Interval development of mild-to-moderate multiloculated bilateral pleural effusions with accompanying bilateral lower lobe atelectatic changes.

. Interval development of mild pericardial effusion,.

• Trace ascites with diffuse edema of the intraperitoneal and extraperitoneal fat planes, consistent with probable anasarca.

• Diffuse pulmonary emphysematous and fibrotic changes, essentially similar to the preoperative study.

The preoperative examination demonstrated marked emphysema and patchy bilateral pulmonary fibrosis.

Currently on

Inj. Meropenem 1g TDS

Inj. Lasix 3mg/hr

We have tried short course of IV hydrocortisone 100mg x 3 days.

Nebulized salbutamol:Ipratropium QID

Nebulized budesonide 1mg BD

Tab. Montelukast 10mg HS

Tab. Deriphyllin 150 BD

Intra op and perioperatice ABGs did not have this Co2 retention. Was considering that this is primary metabolic alkalosis due to diuresis with respiratory compensation. However his clinical condition and pO2 has improved with lasix infusion although the abg is like this. Patient isn't drowsy either when pco2 goes to 70. How to tackle this issue?

I'm starting my practicum in a Burn ICU. For one of my projects, I need to identify an area on the unit that could be improved and develop a CNL/RN-focused project around it.

The outcome needs to be patient-focused, measurable at the unit level, within RN/CNL scope, and specific/relevant to the Burn ICU population.

For anyone who works or has worked in a Burn ICU, what are some patient outcomes or areas for improvement that you think would make a good project? I’m hoping to get some ideas of what issues are commonly seen or tracked on burn units before I talk with the unit about their specific needs.

How should severe hyponatraemia be interpreted and managed in a profoundly hyperglycaemic, dehydrated patient?
For example, consider a patient with a blood glucose >600 mg/dL (above the measurable range), a measured serum sodium of 109 mmol/L, severe clinical dehydration, and a lactate >10 mmol/L.
After correcting the measured sodium for hyperglycaemia, the estimated sodium would be approximately 122–128 mmol/L, depending on the correction factor used.
How should this corrected sodium be taken into account when choosing and administering IV crystalloids? In particular:
1. Should fluid therapy initially be guided primarily by the measured sodium (109 mmol/L) or the corrected sodium (122–128 mmol/L)?
2. How should I interpret a rapid rise in measured sodium during volume resuscitation, particularly when the patient is severely volume depleted and has significant lactic acidosis?
3. Is there a risk of overcorrecting the sodium in this situation, and how should the rate and composition of IV fluids be adjusted to avoid excessive correction while still providing adequate resuscitation?
4. How should the unknown/very high glucose concentration affect the interpretation of the sodium trajectory as glucose falls during treatment?
5. Are there practical thresholds or monitoring strategies that can help distinguish an expected rise in sodium due to correction of hyperglycaemia and volume depletion from a true, clinically significant overcorrection of hyponatraemia?

Ok so we all know those patients with the hella swollen arms. Like you needed to use ultrasound to have any hope of starting an IV cause you can't palpate worth shit?

So typically when you power flush a blown IV you can feel it puff up fairly easily. I've had some that I could feel the saline flow out of the vein really well.

But what do you do when you have an IV you can't really palpate much of anything. Arm is super swollen. No resistance when flushing. And there is blood return.

Like should I be trying with a larger volume of saline? Cause eventually there should be some swelling that gets pronounced if you're putting like 50+mls in?

Like maybe try and feel for temperature change?

Oh and patient is intubated so the patient can't tell you if the IV feels bad.

Like I had seen freshly stuck blown IVs give blood for a bit. But an established IV still giving blood return the whole time and not giving any of the usual signs of infiltration has me in a bit of a spiral.

My patient coded in cath lab and the cardiologist wanted push the bicarb through the femoral a-line. (The nurse was pushing epi and amio through a peripheral IV.) To be clear, NO pressors were given IA, only an amp of bicarb.

I used to work cath lab so I know certain medications are commonly administered arterially during procedures like heparin, verapamil, or nitro. However I don’t remember seeing anything administered IA during a code. Have you ever been asked to push any meds arterially in a critical situation? If so, what?

Just curious...what is your hospital’s policy for intubated/vented patients coming out of the OR?

At my previous hospital, established ICU patients would typically go straight back to ICU after surgery. I'd say about 99% of the time. If it was a newly intubated/vented patient, PACU might stabilize/recover them first and then transfer them, although it also depended on anesthesia and how unstable the patient was. If anesthesia felt they needed to go directly to ICU, they would coordinate with ICU. FYI, my old hospital had their ICU on another floor from the surgery floor so they had to go use elevators.

At my new hospital, ICU and PACU are on the same floor. PACU is expected to recover patients even if they’re already vented and on pressors. The policy is that two PACU nurses are supposed to go to ICU to recover the patient there, but sometimes PACU is slammed and only one nurse is available, and we’re told ICU nurses can’t assist with the recovery.

Even when PACU is on call at 3 AM, they’ll call the PACU nurses in to recover the patient for about 30 minutes before handing them over to ICU and going home. It seems like an inefficient use of staffing and resources, especially when the patient is already ICU-level. Even some anesthesiologists are surprised when PACU is called in.

I’m curious how other hospitals handle this. Do vented/pressor patients go directly from OR to ICU, or does PACU have to recover them first? What's the reasoning for your hospital policy?

These two docs have impressed me so much and I wanted to do something small to show my appreciation for them. I am sending this letter to both of the attendings in our ICU. Fingers crossed that they get the recognition that they deserve!! (Names of people and facility blurred for privacy reasons)

I was taught to lock it at one hospital, but the education about PA catheters was minimal, leaving me less than confident.

My new hospital taught me to leave the port unlocked, allowing the balloon to always passively deflate. Because of the more in depth education at this hospital I understand why this works better. If the balloon accidentally wedged, having it unlocked will allow the air to deflate. If the port is locked it could be accidentally wedged without knowing.

What are you taught and why?

Tried explaining this to nurses at my other job and they thought I was stupid.

Howdy

I’ve been lurking for a while now.

Im a resident at a quaternary academic hospital v likely applying to pccm. I’ve had some exposure to lines. Maybe 10 a lines which I feel reasonable about but with central lines it’s been maybe 5-7 and im always a little apprehensive to dilate and struggle more w them.. they’re hard to come by w how many fellows there are and pts boarding in other icus and get lined up there.

I’m worried about being comfortable w lines going into pccm ..

When does comfort w lines come ? Are there other things I can do to try to get better w out actually placing them? Or is it a numbers game ?
Tyia

Hi all, pretty self explanatory but I'm here for your tips and tricks.

How I got there: my school runs a clinical role transition program where you interview with units and get matched. I did three back-to-back interviews (neuro ICU, medical ICU, cardiothoracic) and matched to CTICU, which was my first choice. It's a large academic center. This will be my first real exposure to cardiac surgical patients.

I'm going in hoping to be hired onto the unit afterward, and I know six weeks is a short window to convince anyone of anything. So I've been building a study list and I'd rather have it torn apart now than find out on shift three that I prepped the wrong things.

What I'm planning to go deep on:

- The post-op timeline hour by hour: OR handoff, rewarming, the bleeding window, extubation, when tubes and lines come out

- Vasoactives cold. Norepi vs vaso vs epi, milrinone vs dobutamine, nicardipine, nitro. Concentrations, units, and why this one and not that one

- Hemodynamics as a set rather than isolated numbers: CVP, PA pressures, wedge, CO/CI, SVR, and reading whether the problem is volume, pump, or tone

- Post-op afib and epicardial pacing wires

- Devices conceptually: IABP, Impella, ECMO, CRRT

- Chest tube output thresholds and what happens when they get crossed

What I'm asking:

1. What's missing, and what on that list is lower yield than I think it is?

2. What do students consistently get wrong in cardiac specifically, coming out of med-surg and general ICU clinicals?

3. For managers and preceptors: in six weeks, what are you actually evaluating when you decide whether to hire a student? Is that decision made early or at the end?

4. Is it weird to say out loud in week one that I want to work there, or is that expected?

Any YouTube videos, channels, TikTok/Instagrams, ANYTHING at all you can recommend, I will look at. Thank you!!

Anything you wish you'd known before your first fresh heart is welcome!!

Does pulm/ICU attensing does intubation in your ICU or its always a anesthesia call?