Balloon tamponade is an effective way to achieve short-term hemostasis in patients with bleeding esophagogastric varices. Due to complications and rebleeding upon balloon deflation, balloon tamponade is reserved for temporary stabilization of patients until more definitive treatment can be instituted (i.e stent placement or TIPS) Initial control of variceal bleeding with balloon tamponade has beenRead more
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The Case: A 50 year old male presents to the emergency room with complaints of shortness of breath. He appears altered, and is not able to provide more history. There is no collateral information available in his chart. Labs reveal a glucose of 300, lactic acid > 15, ph 6.9, + anion gap. Patient isRead more
Serotonin syndrome is a potentially life-threatening condition associated with increased serotonergic activity in the central nervous system. Stimulation of the postsynaptic 5-HT1A and 5-HT2A receptors has been implicated in serotonin syndrome, often due to a medication. The selective serotonin reuptake inhibitors (SSRIs) are perhaps the most commonly implicated group of medications associated with serotonin syndrome.Read more
(Previous posts: work of breathing, mode of ventilation, ventilator alarms) NOTE: this is NOT a peer-reviewed post (pending) and is continuously under construction on the sinaiem.org website! (Last update: 4/18/20) Airway pressure release ventilation (APRV) was used historically as a rescue mode for ARDS, which is classically characterized by heterogeneous lung injury resulting in unevenRead more
(Previous posts: mode of ventilation, work of breathing) As the ventilator alarm grows louder and louder as you walk closer to the room of the patient you just intubated, you review the “DOPES” mnemonic in your head. Except that in the COVID era, you have to be careful with aerosolization (can’t BVM or allow ETTRead more
The spectrum of COVID-19 pulmonary disease is broad, perplexing, and not completely understood as of this writing. But it offers an opportunity to review fundamentals of pulmonary physiology and how it might relate to why/how our interventions (e.g. CPAP, APRV) may work. The following is a first draft (N.B. not peer-reviewed) of my attempt atRead more
(Previous post reviewed work of breathing, next post: ventilator alarm) Even though we often place patients on “volume-control ventilation”, the goal of this post is to precisely define the mode of ventilation, which is often inconsistently or loosely described. It will hopefully serve as the foundation for characterizing other advanced modes. The mode of ventilationRead more
If you were on a tea & toast diet, how much water would you need to drink before you develop hyponatremia? I haven’t seen anyone work out the numbers before so here are my calculations. And the key to understanding hyponatremia is the renal handling of water. Take-home points #1: water follows solutes ⟶ need solutesRead more
As alluded to in the first post, don’t be fooled by a “normal” potassium in the setting of DKA because osmotic diuresis and H+/K+ exchange means that total body potassium is actually LOW. You all know this, but don’t forget to check the potassium before starting insulin. But what about the acidemia? How does that affect physiology? (reminder:Read more
the first symptom of hyperkalemia is death Earlier post covered temporizing measures to counter hyperkalemia — namely, intracellular shift, increasing cardiac myocyte threshold potential. Give furosemide if the patient still urinates and consider dialysis, but then ask yourself: how did the patient get hyper K in the first place? Often, it’s b/c of missed HD. But don’tRead more