Bottom Line Up Top: Steroids provide modest improvement in time to resolution and degree of resolution of symptoms in pharyngitis. They should be considered in patients presenting to the ED after weighing potential benefits and risks. Clinical Scenario: A 22-year-old man with a history of poorly controlled diabetes presents with 3 days of sore throat. Vitals are HR 82, BP 120/73, RR 16, Temp 98.8, O2 sat 99% on RA. He endorses cough and nasal congestion but no fevers. His primary symptoms are sore throat and odynophagia  He has tried over-the-counter NSAIDs with only minor improvement in ..read more

Background: Hypoxemic respiratory failure is a frequent complicating feature of severe COVID-19 infection. Early in the pandemic, extensive efforts were made to identify the best approach to oxygenation in this group of patients. Best practices settled on aggressive use of non-invasive ventilation (NIV) and delaying invasive mechanical ventilation (IMV) where feasible. Advanced interventions include proning (both on NIV and IMV) and extracorporeal mechanical oxygenation (ECMO). As therapies are escalated, it’s critical for clinicians to have high-quality data on target oxygen levels. Paper: N ..read more

Introduction: Resuscitationists continue to debate the choice of induction agents in rapid sequence intubation (RSI). Critics of etomidate highlight its link to adrenal suppression in critically ill patients (Albert 2011), while critics of ketamine highlight the higher incidence of post-intubation hypotension (Mohr 2020). Amidst the debate, the Ketased Trial (Jabre 2009), a large multicenter prospective, single-blind randomized clinical trial (RCT), reported no significant difference in SOFA scores or 28-day mortality between the two induction agents. However, the EvK trial (Matchett 2022) id ..read more

Background: Although most intubations are typically successful there is still a portion of patients that may require multiple intubation attempts.  Repeated intubation attempts could lead to respiratory and hemodynamic complications. We recently covered the DEVICE trial on REBEL EM which compared a standard geometry video laryngoscopy approach vs a standard geometry direct laryngoscopy approach in critically ill adults requiring intubation.  Video laryngoscopy outperformed direct laryngoscopy in first pass intubation success (85.1% vs 70.8%). We now have a second trial in an operati ..read more

Background: Hematologic emergencies in the critical care setting are rare but deadly complications that can often be managed appropriately if identified early on and received prompt intervention. In this 2-part review, we will discuss several hematologic emergencies and discuss the literature on current guidelines and principles of management. Shoon Oo MD1 , Vinh Dao MD1, Kenneth Snell MD2, David Goldenberg DO2, Frank Lodeserto MD3 Affiliations 1. Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, North Carolina 2. Department of Anesthesiology, H. Lee Moffitt Canc ..read more

Background: Hematologic emergencies in the critical care setting are rare but deadly complications that can often be managed appropriately if identified early on and received prompt intervention. In this 2 part review, we will discuss several hematologic emergencies and discuss the literature on current guidelines and principles of management. Vinh Dao MD1, Shoon Oo MD1, Kenneth Snell MD2, David Goldenberg DO2, Frank Lodeserto MD3 Affiliations 1. Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, North Carolina 2. Department of Anesthesiology, H. Lee Moffitt Cance ..read more

Background: The mainstay of treatment for symptomatic pulmonary embolism  (PE) is anticoagulation (AC).  Patients with higher-risk PE may require advanced interventions such as thrombolytic therapy, surgical thrombectomy, or even extracorporeal membrane oxygenation (ECMO). Because of its short half-life and availability of a reversal agent, unfractionated heparin (UFH) is commonly used when percutaneous or surgical interventions are being considered. The standard weight based dosing of UFH is 80U/kg bolus followed by an infusion started at 18U/kg/hr, titrated to a target activated p ..read more

Take Home Points Salicylates are a commonly used and widely prescribed xenobiotic due to their analgesic, anti-inflammatory, and anti-pyretic properties. Common preparations include aspirin, methyl-salicylate (Oil of Wintergreen), and bismuth-subsalicylate (Pepto-Bismol). Salicylate toxicity should be considered in the patient with tachypnea, clear lungs, and some degree of acid-base disturbance. Mainstays of management include: GI decontamination, serum and urinary alkalinization, electrolyte repletion, and hemodialysis. Avoid intubation if possible. Given the increased minute ventilation o ..read more

Background: Nitrates can help improve symptoms and ischemia in the setting of acute myocardial infarction. Current teaching holds that nitrates should be avoided in patients with potential right ventricular myocardial infarction (RVMI), due to the risk of decreasing preload and precipitating hypotension. This belief is based on a single 1989 study of 40 patients with RVMI and endorsed by both the AHA and ESC guidelines [2]. In that 1989 study, of the 40 patients with RV infarction 20 had a decrease in blood pressure of ≥30mmHg and associated symptoms after the administration of nitrates (SL ..read more

Background: Elevated intracranial pressure in patients with acute brain injury is a neurologic emergency requiring early recognition and early aggressive treatment to prevent progression to cerebral ischemia, brain herniation, and ultimately death.  There are two primary options for treatment in terms of hyperosmolar agents: mannitol and hypertonic saline (HTS). Both agents have pros and cons, but both are effective in rapidly reducing brain volume and ICP. Bolus administration of HTS has become favored due to its rapid effect and more transient increase in serum sodium levels compared t ..read more