Acute Disorders of Consciousness

Today, we are revisiting one of our favorite episodes from last year - The Forgotten Patient. Dr. Zanotti focuses on the loved ones and families of critically ill patients and explores the topic through the lens of a cardiac arrest co-survivor. His guest is Kristin Flanary, a cognitive neuroscientist and social psychologist. Kristin is a co-survivor of cancer(twice) and a co-survivor of sudden cardiac arrest. She is also known for her social media alter ego – Lady Glaucomflecken. In 2022 Kristin co-founded Glaucomflecken LLC, where she works to advocate for caregivers and co-survivors of medical trauma and critical illness, community CPR and AED use, and sudden cardiac arrest survivorship. She has written about her experience as a co-survivor in medical journals and has received an EMS Cardiac Arrest Save Challenge Coin, the Citizen CPR Foundation’s '40 Under 40' award, and the American Heart Association’s Resuscitation Champion award. Additional Resources: The Quiet Place. K. Flanary. Journal of Cardiac Failure, 2021: www.onlinejcf.com/article/S1071-91…00403-6/fulltext Roger. K Flanary. CHEST. 2022: journal.chestnet.org/article/S0012-…029-6/fulltext Life after Cardiac Arrest: The importance of engaging with the “forgotten patient.” K Haywood & K Dainty. Resuscitation, 2018: www.resuscitationjournal.com/article/S0…0195-3/pdf Link to the Glaucomflecken’s website: glaucomflecken.com/ Books Mentioned in this Episode: In Shock. By Rana Awdish: bit.ly/441b0Cx

In this episode, Dr. Zanotti covers temporary pacing in the ICU. He is joined by Dr. Christopher Noel, a Critical Care Attending at Cooper University Healthcare, and an Assistant Professor of Medicine at Cooper Medical School of Rowan University. In addition, Dr. Noel is the Associate Program Director for the Critical Care Medicine Fellowship and the Director of the Medical Student Critical Care Clerkship. Additional resources: Temporary Epicardial Pacing After Cardiac Surgery. Cronin b, et al. Journal of Cardiothoracic and Vascular Anesthesia 2022: https://pubmed.ncbi.nlm.nih.gov/36180288/ Temporary epicardial pacing after cardiac surgery: a practical review. Part 1: General considerations in the management of epicardial pacing. M.C. Reade. Anesthesia 2007: https://pubmed.ncbi.nlm.nih.gov/17300304/ Temporary epicardial pacing after cardiac surgery: a practical review. Part 2: Selection of epicardial pacing modes and troubleshooting. M.C. Reade. Anesthesia 2007: https://pubmed.ncbi.nlm.nih.gov/17381573/ Medtronic Educational Resources on Temporary Pacemakers: https://www.medtronic.com/us-en/healthcare-professionals/products/cardiac-rhythm/pacemakers/temporary-external-pacemakers.html Books mentioned in this episode: Crucial Conversations: Tools for Talking When Stakes are High. By Joseph Grenny, et al.: https://bit.ly/3XWFo0d The Mutiny on the Bounty. By Peter FitzSimons: https://bit.ly/4cwGkNb

Disturbances in neurological function due to primary neurological disorders or organ failure from critical illness are common in patients admitted to the ICU. In this episode, Dr. Zanotti discusses the neurological physical exam in the ICU. He is joined by Dr. Adam Rizvi, a neurologist with Neurocritical care and vascular neurology fellowship training who currently practices critical care, neurocritical care, and tele-neurology/tele-stroke in several hospitals in California. In addition to his clinical work, Dr. Rizvi is an accomplished educator and researcher. Additional Resources: Neurological examination of critically ill patients: a pragmatic approach: Report of an ESICM expert panel. Intensive Care Med 2014. https://pubmed.ncbi.nlm.nih.gov/24522878/ Critical Matters Podcast episode: Brain Death / Death by Neurological Criteria. Host: S. Zanotti. Guest: D. Greer: https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=1677810255 Clinical Neuroanatomy Made Ridiculously Simple. Edition 6. Stephan Goldberg, MD: https://amzn.to/4cC34uZ Books mention in the episode: Meditations. By Marcus Aurelius. Translation by Gregory Hayes: https://amzn.to/4eBxK1d

This is the second part in our series discussing temporary mechanical circulatory support (tMCS). Part one, covered different types of devices for tMCS, pathophysiology of shock, clinical indications, and general considerations for critical care clinicians. In Part 2, Dr. Zanotti covers a more detailed discussion of medical management and troubleshooting of patients on tMCS. He is again joined by Bindu Akkanti, MD, an associate professor in the Division of Pulmonary, Critical Care, and Sleep Medicine at UTHealth Houston. Dr. Akkanti is the Medical Director of the Heart Failure ICU and the Director of Critical Care for the Heart & Vascular Institute at Memorial Hermann Texas Medical Center. Additional Resources: More about Dr. Akkanti: https://med.uth.edu/internalmedicine/2022/11/17/bindu-akkanti-md/ Mechanical Circulatory Support Part 1 - Critical Matters Podcast. https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=1828006629 A Comprehensive Review of Mechanical Circulatory Support Devices. V Atti, et al. Heart Intl. 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9524665/ American Society of Artificial Internal Organs website. https://asaio.org/ IABP: Hemodynamics, troubleshooting, technical tips. https://www.youtube.com/watch?v=ULgjuhBgP9U Composer and Musician A.R. Rahman. https://www.arrahman.com/

In the first part of this two-part series, Dr. Zanotti is joined by Bindu Akkanti, MD, an associate professor in the Division of Pulmonary, Critical Care, and Sleep Medicine at UTHealth Houston. Together, they discuss temporary mechanical circulatory support, an increasingly vital modality in treating cardiogenic shock and other subsets of critically ill patients in shock. Dr. Akkanti is the Medical Director of the Heart Failure ICU and the Director of Critical Care for the Heart & Vascular Institute at Memorial Hermann Texas Medical Center. Additional Resources: More about Dr. Bindu Akkanti: https://med.uth.edu/internalmedicine/2022/11/17/bindu-akkanti-md/ Review of Pathophysiology of Cardiogenic Shock and Escalation of Mechanical Circulatory Support Devices. Pahuja M, et al. Curr Cardiol Rep 2023: https://pubmed.ncbi.nlm.nih.gov/36847990/ Temporary mechanical circulatory support devices: practical considerations for all stakeholders. Salter BS, et al. Nature Reviews Cardiology 2023: https://www.nature.com/articles/s41569-022-00796-5 Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock. Moller JE, et al. N Engl J Med 2024: https://www.nejm.org/doi/full/10.1056/NEJMoa2312572 Books Mentioned in this Episode: The Alchemist. By Paulo Coelho: https://bit.ly/3yv4Zmt

With over 700 modes of mechanical ventilation available today, it can be overwhelming to find the best application of technology at the bedside. Focused on goal-directed mechanical ventilation, this discussion covers the taxonomy of mechanical ventilation modes and provides a framework for a rational approach at the bedside. Dr. Zanotti is joined by Dr. Eduardo Mireles-Cabodevila, Director of the Medical Intensive Care Unit and the Simulation and Advanced Skills Center at the Cleveland Clinic. In addition, Dr. Mireles-Cabodevila is the Vice-Chair of the Division of Critical Care Medicine, Department of Pulmonary and Critical Care, within the Integrated Hospital-Care Institute at the Cleveland Clinic. Additional Resources: How do I ventilate patients with ARDS: Goal-directed mode selection. E. Mireles-Cabodevila. Med Intensiva 2022: https://pubmed.ncbi.nlm.nih.gov/36220727/ A Rational Framework for Selecting Modes of Ventilation. E. Mireles-Cabodevila, et al. Respir Care 2013: https://pubmed.ncbi.nlm.nih.gov/22710796/ Closing the Gap in Patient-Ventilator Discordance Recognition. A. Liendo and E. Mireles-Cabodevila. Respir Care 2024: https://pubmed.ncbi.nlm.nih.gov/38267228/ Standardized Education for Ventilatory Assistance (SEVA) resources page; https://my.clevelandclinic.org/departments/respiratory/medical-professionals/seva#seva-resources-tab Mechanical Ventilation Mode Taxonomy App: iPhone: https://apps.apple.com/us/app/ventilator-mode-map/id1508307955 Android: https://play.google.com/store/apps/details?id=org.ccf.vmm&hl=en_US Books mentioned in this episode: Solito: A Memoir. By Javier Zamora: https://bit.ly/4b6hPG8

In this episode, Dr. Zanotti discusses the management of acute life-threatening asthma exacerbations in the ICU with this guest, Dr. Haney Mallemat, a physician trained in EM/IM and Critical Care. Dr. Mallemat is currently an Associate Professor of Emergency Medicine and Internal Medicine at the Cooper Medical School at Rowan University. Additional Resources: How Not to Kill an Asthmatic – Presented at CODA Change by Haney Mallemat: https://codachange.org/severe-asthma Management of Acute Life-Threatening Asthma Exacerbations in the Intensive Care Unit. Talbot T, et al. Appl. Sci 2024: https://www.mdpi.com/2076-3417/14/2/693 ResusX,- a medical resuscitation conference created by Dr. Mallemat: https://www.resusx.com Last Week Now! - A curated newsletter by ResusX: https://www.resusx.com/newsletter Keynotable – a course for beginners and seasoned speakers: https://www.keynotable.net Books mentioned in this episode: How to Win Friends and Influence People. By Dale Carnegie: https://bit.ly/49WlcOd

In this episode, Dr. Zanotti is joined by Dr. Stephen Pastores to discuss the 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia, published by the Society of Critical Care Medicine. Dr. Pastores is Program Director for Critical Care Medicine and Vice-Chair of Education for the Department of Anesthesiology and Critical Care Medicine at Memorial Sloan Kettering Cancer Center. In addition, Dr. Pastores is a professor of anesthesiology and medicine at Weill Cornell Medical College in New York, NY. Additional resources: 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia. Crit Care Medicine 2024: https://journals.lww.com/ccmjournal/pages/articleviewer.aspx?year=9900&issue=00000&article=00275&type=Fulltext Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. ADRENAL Trial. N Engl J Med 2018. https://www.nejm.org/doi/full/10.1056/NEJMoa1705835 Hydrocortisone plus Fludrocortisone for Adults with Septic Shock. APROCCHSS Clinical Trial. N Engl J of Med 2018: https://www.nejm.org/doi/full/10.1056/NEJMoa1705716 Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomized controlled trial. The Lancet 2020: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(19)30417-5/abstract Hydrocortisone in Severe Community-Acquired Pneumonia. CAPE-COD Trial. N Eng J Med 2023: https://www.nejm.org/doi/full/10.1056/NEJMoa2215145 Books mentioned in this episode: Elon Musk. By Walter Isaacson: https://bit.ly/3PVXWsG The Autumn Ghost: How the Battle Against a Polio Epidemic Revolutionized Modern Medical Care. By Hannah Wunsch: https://bit.ly/4avevns

In this episode, Dr. Zanotti discusses the delicate balance of conflict resolution in healthcare. Conflict is common in our daily work in the ICU. Many clinicians avoid conflict and have negative feelings towards it. However, conflict, when managed appropriately, can lead to significant benefits for our patients and teams. Dr. Zanotti's discussion is based on a webinar he presented earlier this month as part of Sound Critical Care Leadership Week. Additional Resources: Watch the full webinar: https://youtu.be/R3wz29W3C4g Conflict Management in the ICU. Previous Critical Matters podcast episode with Dr. Joshua Kayser. https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=1378454077 Books Mentioned in this Episode: Nonviolent Communication. By Marshal B. Rosenberg: https://bit.ly/4a8h0fp Getting to YES: Negotiating Agreement Without Giving In. By Roger Fisher and William Ury: https://bit.ly/3TSD5J3 Possible: How We Survive (and Thrive) in an Age of Conflict. By William Ury: https://bit.ly/4aauFCK Crucial Conversations: Tools For Talking When Stakes are High. By Joseph Grenny, et al: https://bit.ly/43AU6La The Anatomy of Peace: Resolving the Heart of Conflict. By the Arbinger Institute: https://bit.ly/4a1v0HL

In this episode, Dr. Zanotti is joined by Dr. Craig Rackley to discuss the role of ECMO – extracorporeal membrane oxygenation in supporting patients with acute respiratory failure. Dr. Rackley is a practicing pulmonary critical care physician and an associate professor of Medicine at Duke University School of Medicine. He is the medical director of Adult ECMO in the Duke Division of Pulmonary, Allergy, and Critical Care Medicine. Dr. Rackley is also a recognized clinician, educator, and researcher interested in respiratory failure, ARDS, and ECMO. Additional Resources Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. The CESAR Trial. Lancet 2009: https://pubmed.ncbi.nlm.nih.gov/19762075/ Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. The EOLIA Trial. N Eng J of Med 2018: https://www.nejm.org/doi/full/10.1056/NEJMoa1800385 Bertini P, Guarracino F, Falcone M, et al. ECMO in COVID-19 Patients: A Systematic Review and Meta-analysis. J Cardiothorac Vasc Anesth 2022: https://pubmed.ncbi.nlm.nih.gov/34906383/ Books mentioned in this episode Endurance: Shackleton’s Incredible Voyage. By Alfred Lansing: https://bit.ly/43g71C1 South!: The Story of Shackleton’s Last Expedition 1914-1917. By Ernest Shackleton: https://bit.ly/49NyJbU