A 36-year-old woman presented to urgent care with cough, dyspnea and hypoxemia. She was transported to the ED where she rapidly progressed to severe ARDS despite lung protective ventilation, paralysis and inhaled epoprostenol. Post-intubation, it was determined that she was pregnant with ultrasound revealing a fetus at 23 weeks, 6 days gestational age. She underwent cannulation for venovenous ECMO. What is the role of ECMO in the pregnant patient? A recently published analysis of the ELSO registry for peripartum patients supported with ECMO demonstrates a 70 percent survival rate.
You sign out to the overnight team at midnight and stay an hour or so completing a laceration repair and finishing your charts. It's been a chaotic afternoon and evening and the patina of COVID-19 didn’t make things any better. After your shift (and appropriate decontamination) you pass your hospital’s new resiliency resource room. You wonder, “What would be more relaxing right now? Doing some deliberative coloring, petting a dog, or just heading home?”
You are working in a busy ED when a patient who is 54 arrives with an acute onset headache associated with syncope but no focal neurologic deficits. His physical exam is unremarkable but his BP is mildly elevated at 175/80. The patient’s head CT is consistent with an aneurysmal subarachnoid hemorrhage. You begin anti-hypertensive treatment, but wonder how reliable non-invasive blood pressure measurement is in this patient.
During the current pandemic, physicians are findings themselves interfacing with the public and talking about topics they never thought they would have to consider. One way to prepare for this is to develop a library of phrases ahead of time which can be used in the appropriate context. It can also be helpful to generate analogies to common objects/systems to assist the general public in understanding critical care concepts.
Like all medical therapies, we have learned that treatment with oxygen comes at a cost. The medical literature is replete with the detriments of hyperoxia in the management of myocardial infarction, acute stroke, cardiac arrest and septic shock. What is the optimal oxygenation target for critically ill patients requiring mechanical ventilation? Three landmark trials can guide us: Oxygen-ICU, ICU-ROX and LOCO2. The end to the oxygenation fairytale remains to be told, but perhaps Goldilocks is “just right.”