Critical Care Scenarios

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131 reviews
This podcast has
77 episodes
Date created
Last published
Average duration
30 min.
Release period
7 days


Join us as we talk through clinical cases in the ICU setting, illustrating important points of diagnosis, treatment, and management of the critically ill patient, all in a casual, "talk through" verbal scenario format.

Podcast episodes

Check latest episodes from Critical Care Scenarios podcast

TIRBO #12: On heroics (or: is critical care hard?)
Some musings in response to people who are impressed by the work we do.
Episode 48: Undifferentiated hypotension
Brandon walks Bryan through a case of new, unexplained hypotension in the ICU, with a focus on approaching shock, the use of POCUS, and risk stratifying unexplained problems. Takeaway lessons * Sudden changes in vital signs or other status are often due to precipitating factors, such as iatrogenic stimuli, whereas more gradual changes are often due to evolution of the underlying diseases. This is not always reliable.* Sudden changes can also be due to monitoring artifacts, such as inaccurate telemetry, problematic arterial lines, etc.* Failing arterial lines are usually damped (reduced amplitude), causing depressed systolic pressures and raised diastolics, but the MAP still tends to still be reliable.* Hypotension with a narrower pulse pressure is somewhat more suggestive of hypovolemia than vasodilation. This is not always reliable.* Point-of-care ultrasound is probably the single best tool for assessing unexplained hypotension, mainly because it can (within a few seconds) rule out most of the life-threatening, specifically treatable causes, such as cardiac tamponade, PE, cardiogenic shock, major hemorrhage, and tension pneumothorax. Distributive shock (e.g. from sepsis), while among the most common causes of hypotension in the ICU, is a diagnosis of exclusion.* A fluid bolus used diagnostically should be given fast, and all the faster if you’re not giving very much volume. Use a pressure bag and don’t leave the room.* One of the hardest acts of judgment in a clinician is to recognize whether a new finding is a “big deal” or not.
TIRBO #11: Mastering wire guidance
Advanced techniques for manipulating the guidewire during non-fluoroscopic bedside procedures such as central line placement.
Lightning rounds #16: How we do case-based teaching
Brandon and Bryan talk about how they assemble, implement, and leverage case-based learning, from this podcast to simulation to oral scenarios to internal visualization.
TIRBO #10: Put the I back in Team
When it’s a bad idea to help out others with their work.
Episode 47: ICU triage with Eddy Gutierrez
Discussing ICU triage, risk stratification, and patient disposition with intensivist Eddy Joe Gutierrez (@eddyjoemd) of the Saving Lives Podcast. For 20% off the upcoming Resuscitative TEE courses (through July 23, 2022), listen to the show for a promo code for CCS listeners! Takeaway lessons * When a patient has borderline indications for requiring the ICU, generally, in the real world, they should go to the ICU. More often than not, “downtriage” results in a later, inevitable, yet delayed upgrade to the ICU.* Sometimes, borderline patients may need the ICU just to complete the workup and prove that they don’t need the ICU. This is annoying but inevitable; such patients can’t languish for a 12-hour evaluation in the ED no matter how much we might want them to. The ED needs to flow, and there’s no better diagnostic tool than time.* A good practical rule for which pulmonary emboli require the ICU are those that will, or may, require an intervention other than systemic anticoagulation. Examples include systemic thrombolysis, catheter-directed thrombolytics, thrombectomy, etc.* In theory, patients with a downward trajectory can remain outside the ICU until they reach the point where they require critical care, then can be upgraded. This can work as long as their deterioration is controlled and not precipitous, i.e. there’s time to safely recognize their status and move them to higher care when the time comes. But this is often not easy to know.* The location of care can influence care in non-obvious ways. For instance, a septic patient may receive excessive harmful IV fluid boluses as providers attempt to avoid an upgrade to the ICU to administer vasopressors.* Bed availability has no relation to patient disposition, other than the fact that patients forced to board outside the unit will probably, inevitably receive worse care.* The readiness to transfer a patient from the ICU is usually higher than the threshold for accepting them initially. This isn’t a fallacy. It’s due to the fact that the former has had a period of observation, whereas the latter has not yet demonstrated their trajectory.* When a sending provider (e.g. in the ED, floor, or an outside hospital) thinks a patient needs the ICU, and you don’t think so, they usually should win. A patient may not need the ICU, but if they can’t stay where they are, uptriage is the safety net.* Ultimately, safe triage is usually a process, not a snapshot, and patients may need to move more than once. Smooth and safe transfers of care usually comes down to details and knowledge of your specific institution, and navigating it well requires good communication. Teams that can’t talk to each other inevitably lead to deficiencies in care.* Making certain triage determinations by policy, committee, or guideline can help counteract the natural tendency (at least in the US) to always overtriage due to concern about personal provider risk.* Try to limit your second-guessing about other people’s triage decisions made in retrospect. It’s a lot easier after the fact.
TIRBO #9: Some quotes about why
A selection of lesser-known quotes relevant to the practice of medicine.
Lightning rounds #15: Night shifts
Bryan and Brand talk about night shifts, how to handle them, managing the disruption of your circadian rhythm, and more. For 20% off the upcoming Resuscitative TEE courses (through July 23, 2022), listen to the show for a promo code for CCS listeners!
TIRBO #8: What does skin really tell you about hemodynamics?
The relationship between skin warmth and color, cardiac output, and systemic vascular resistance. For 20% off the upcoming Resuscitative TEE courses (through July 23, 2022), listen to the show for a promo code for CCS listeners!
Episode 46: Neurologic catastrophe and brain death with Casey Albin
We review a case of massive intraparenchymal hemorrhage progressing to brain death, including the process of brain death testing and declaration, with Dr. Casey Albin (@CaseyAlbin), neurologist and neurointensivist, assistant professor of Neurology and Neurosurgery at Emory and part of the NeuroEmcrit team. For 20% off the upcoming Resuscitative TEE courses (through July 23, 2022), listen to the show for a promo code for CCS listeners! Takeaway lessons * In general, in patients with good baseline function, it’s reasonable to be fairly aggressive with initial care, such as placement of intracranial pressure monitors, even if long-term goals of care are unclear—it can always be escalated.* Although ICH score is associated with mortality, the original study allowed withdrawal of care at discretion of the clinicians, so the data may be tainted by self-fulfilling prophecy—withdrawal of care may lead to poor prognosis in some cases, not always the reverse.* Sodium goals are ideally titrated to ICP (with invasive monitoring). In its absence it’s best to target clinical findings, unless you have tools like TCDs or optic nerve sheath ultrasound, or just frequent CT scans. Arbitrary sodium goals are rarely helpful.* There is good evidence for decompressive hemicraniectomy for large MCA infarct IF the patient is young; it is less clear in the elderly. If it’s going to be done, do it early.* If herniation is clear via ICP or imaging, don’t spare sedation for the sake of a neuro exam, unless you’re at the point of stepping back and assessing for long-term futility and possible brain death.* 4-5 days into admission is often when families begin to understand the nature of a devastating neurologic injury. In some cases, discussion of futility and brain death may be initiated by families after doing their own research.* The first step is holding sedation and waiting ~5 half-lives for confounding drugs to clear; impaired renal or hepatic clearance should be taken into account here. (Pharmacy may be helpful.) Paralysis should be held and train-of-four can be used to confirm. Drug levels can be used to confirm clearance of opioids, etc if needed.* The law (Uniform Declaration of Death Act) doesn’t always agree with guidelines (while hospital policies may differ even further). The UDDA requires complete brain death, whereas the AAN’s guidelines don’t necessarily require pituitary death (patient need not be in DI), but all do require more than just brainstem death—for example, a locked-in patient would not qualify. * Expect and manage DI, as hypovolemia and hypernatremia may make the patient too unstable to tolerate brain death testing. Consider a vasopressin drip, replace volume, etc.* As the chest wall becomes denervated, it loses elastic recoil, while hypovolemia may cause very hyperdynamic cardiac function. The combination can cause strong chest wall vibrations which may autotrigger the ventilator, often confusing staff and family who believe the patient is breathing spontaneously.* Perform brain death testing in a systematic, scrupulous manner. Print your hospital policy and use it as a formal checklist. You’ll need a bright penlight, a tongue depressor or Yankhauer catheter, a Q-tip or gaue for corneal reflexes, 50 ml x2 of ice-cold water and a syringe with an IV catheter on the tip for cold calorics, and some kind of insufflation catheter or a T-piece for apnea testing. * Pitfalls: remember to test corneals by touching the actual cornea, not the sclera. Cold calorics are performed by irrigating the ear canal and watching for gaze deviation (any deviation shows brainstem activity).
TIRBO #7: Selecting vasopressors
A practical approach to choosing and escalating vasopressors for patients in shock.
Lightning rounds #14: Abdominal compartment syndrome
Brandon and Bryan discuss a practical approach to abdominal compartment syndrome: when to suspect it, confirming the diagnosis with bladder pressure or other monitoring, management, and prognosis. Sorry for the audio on this one!

Podcast Reviews

Read Critical Care Scenarios podcast reviews

4.6 out of 5
131 reviews
A. Kiser 2022/05/25
Love the content
There is no doubt that the proper work is being done to put these episodes together. I absolutely love the turbo episodes, specifically number nine. I...
A kizhakkedath 2022/01/24
A regular listener . Great topics and guests . I worked as an icu nurse for 13 yrs before starting my career as an icu np . Critical care is a team sp...
_Murse_Dreadd_ 2022/03/07
Howdy, Howdy!!
Hey guys.. new listener here! I’m a 5 year ICU Murse and current Adult-Geri Acute Care NP student. Just wanted to say I often struggle to listen to P...
NCCU NP 2022/01/09
I appreciate they have honed in on this effective method of teaching. Well done!
coleygonzo 2021/11/03
Really useful podcasts that doesn’t waste my time
So nice to hear practical discussions of cases. I’ve been looking for a podcast like this and I’m so happy to have found it. I also REALLY appreciate...
JeffONYC 2021/10/20
Excellent source of information!
I love this podcast! As an ICU nurse, it’s very enjoyable to listen to doctors as they talk through their reasoning with different patients.
Impact Factor 2021/07/10
Excellent for anyone who steps foot in an icu
auntywu 2021/09/06
Good but…
Just curious with the most recent podcast why it was presented as a “54 y/o UNVACCINATED” individual. Why does that matter? Didn’t science & research ...
Turbotext 2021/07/03
Invaluable podcast!
As a new grad ICU nurse, this podcast is so incredibly helpful. There’s so much information that can be learned for these case studies. I have listene...
Meepmeep1235739277 2021/05/02
This podcast is awesome! As an ICU RN and almost graduating NP, these case scenarios are so helpful in not just understanding a concept but how to app...


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