Diagnosing Pericarditis: -Pericardium is electrocardiographically silent -Pericarditis w/ ECG changes = pericarditis w/ epicarditis or pericarditis w/ myocarditis. -If troponin markedly elevated, trending up or patient looks toxic, admit to workup myocarditis youtube.com/shorts/jI6Zp... #EMIMCC

Replace blood w/ blood -No role for crystalloid in resus of a shocky trauma patient - dlutes hgb + clotting factors -What if no blood? 1) Transport 2) Stop bleeding: tourniquet, direct pressure, pelvic binder 3) Tolerate lower BP + consider vasopressors youtube.com/shorts/u0J9i... #EMIMCC

Don’t forget to fluid load in sick asthma -Huge insensible losses from incr RR + WOB -If need intubation, pos pressure vent results in incr intrathoracic pressure dropping pulmonary venous return ➡️HD collapse -Load early w/ 20-30 cc/kg of crystalloid to avoid youtube.com/shorts/mbOzE... #EMIMCC

Ca2+ doesn’t stabilize cardiac myocytes in hyperK -Lab data: Ca2+ restores Ca2+ dependent propagation -Doesn’t matter clinically as Ca2+ will reverse hyperK induced ECG changes -Ca2+ still treatment of choice in hyperK w/ significant ECG changes like QRS widening youtube.com/shorts/Ofr-D... #EMIMCC

@emswami.bsky.social guides us through some practical tips and limitations for IO placement in the crashing patient on this month's EM Quick Hits Video emergencymedicinecases.com/video/em-qui...

cosign this 😁 four-factor PCC had clotting factors & *also* endogenous anticoagulants (protein C & S, antithrombin III) that’s why PCC doesn’t cause as much thrombosis: it’s rebuilding the coagulation cascade rather than purely functioning as a pro-thrombotic (& Adnexanet alfa price is insane)

Time to Ditch Andexanet Alfa? -ANNEXA-1: No mortality benefit, incr VTE -Real world data: Rech 2025 (PMID:40700941) no improved outcomes, 9% incr VTE w/ andexanet alfa (NNH = 11) Mounting evidence that andexanet offers no benefit while increasing complications youtube.com/shorts/7DGcv... #EMIMCC

Simplifying the Vent -5 parameters: Mode, RR, TV, PEEP + FiO2 -Default approach: Lung Protective Strategy -Assist Control (AC) appropriate for most -RR 12-14, TV 6-8 cc/kg IBW. Incr RR to incr ventilation 5) Titrate PEEP + FiO2 together to achieve O2 sat over 92% youtube.com/shorts/sLdOz... #EMIMCC

Epinephrine in asthma -Crashing asthmatic pts may not respond to inhaled bronchodilators: severe bronchoconstriction limits med delivery -Parenteral bronchodilators ➡️ rapid bronchodilation + can be life-saving -Parenteral Epi dose: 0.5 mg IM or 50 mcg IV youtube.com/shorts/MlQu5... #EMIMCC

🫀VTach Treatment starts w/identifying underlying cause 4️⃣Here's a REBEL REVIEW describing 4 ways to manage this life-threatening arrythmia! 👀More at https://loom.ly/LNw6HwY #FOAMed @emswami.bsky.social @mramzydo.bsky.social

Early vasopressin in pts w/ liver failure + those on ACEI/ARB 1) Liver failure: vasopressin deficient. Can start early in sepsis, hepatorenal or even GI bleed 2) ACEI/ARBs theoretically reduce endogenous vasopressin stimulation Dose: 0.03 - 0.04 U/min IV infusion youtube.com/shorts/5W7iM... #EMIMCC

Bougie Scissor Grip -Hold bougie between 3rd + 4th digits (instead of pencil grip) -4th digit is fulcrum + allows you to apply pressure w/ 3rd digit moving coude tip anteriorly -Scissor grip gives better control of bougie allowing you to change direction of tip youtube.com/shorts/wLsSU... #EMIMCC

Trauma + Shock: Where's the blood? 5 Options in adults: chest, abdomen/pelvis, retroperitoneal space, long bones, street Can get chest/abdomen w/ eFAST Can get long bone from physical + street from history RP space is a black box - need CT to get that info youtube.com/shorts/kRWsd... #EMIMCC

ED Resuscitative Thoracotomy -L sided thoracotomy gives you access to heart + aorta but not to R chest -If you do a L sided thoracotomy, you still need to do a R sided thoracostomy -If there’s significant blood from the R chest, extenend incision to a clamshell youtube.com/shorts/k5Pr3... #EMIMCC

This is a great way to use LLMs in medicine. Simply letting the LLM do all the work will invariably lead to numerous issues but a "triple-threat" approach makes a lot of sense @pulmcrit.bsky.social emcrit.org/pulmcrit/tri...

Anticipate hypotension in every RSI patient. The literature says that post-intubation hypotension is extremely common, regardless of which medications or dosages you select. In some studies 40% to 50%. Push dose epi prepped for EVERY RSI. And if at all shocky, start low dose norepi infusion.

Rocketamine Dosing -Ketamine:1.5 mg/kg -Roc standard dose (0.6 mg/kg) w/slow onset (90-120 sec) -Roc 1.2 mg/kg faster:45-60 sec -Issues w/ 1.2 mg/kg: in shock, paralytic onset delayed + hard to multiply by 1.2 in high-risk scenarios -Go w/ 1.5 mg/kg instead youtube.com/shorts/vehIN... #EMIMCC

Cerebral Edema in DKA -Can result in rapid neurological deterioration -Assoc w/ fluid volume + bicarb but no causality -Key: prompt identification + rapid tx -Clinical diagnosis: lethargy, new neuro signs/symptoms -Treatment: 3% hypertonic saline 3 cc/kg youtube.com/shorts/65vMI... #EMIMCC

Rhythm check + pulse check not same: rhythm check looks for electrical activity, pulse check for mechanical activity -Rhythm= VF/VT, no need waste time on pulse. Defib + resume compressions -Rhythm= organized cardiac activity, check for mechanical activity w/ US youtube.com/shorts/72F17... #EMIMCC

Andexanet alfa increases VTE w/o offering improved clinical outcomes bit.ly/41oy4vm -660 patients AA or 4FPCC -No mortality benefit for andexanet -9% increase in VTE (NNH = 11) Not perfect data but mounting evidence that this massively expensive drug offers no benefit w/ incr complications

Gag Reflex + Airway Protection -Classic teaching: no gag = can vomit, aspirate. Massive oversimplification -40% w/ no gag at baseline -Checking gag (if intact) incr chance for vomit + aspiration -Don’t check gag in AMS + don’t intubate due to absence of gag youtube.com/shorts/waPQj... #EMIMCC

Pelvic Binders Logistics Key: Indiscriminate application in significant blunt trauma w/ any HD instability Don’t “rock the pelvis” - dislodges clots, increases bleeding + pain Logistics: place binder on gurney + transfer pt directly from EMS stretcher onto binder youtube.com/shorts/YaWUP... #EMIMCC

this is such a great video 👇 The phenomenon of a partially-displaced chest tube that pushes air into the subcutaneous tissue & leads to massive SQ emphysema is under-recognized but can be a huge problem. A malpositioned tube can make SQ emphysema WORSE. (more on this: emcrit.org/pulmcrit/mic...)

Is Your Chest Tube In the Right Place? -Should see tidaling: oscillation in the H2O seal chamber -Should see bubbling in the H20 seal chamber -SubQ emphysema shouldn’t be increasing (means side port of drain is outside pleural cavity) youtube.com/shorts/qBt4_... #EMIMCC

Standard Geometry Blade Laryngoscope Grip Tips: 1) Grasp near blade to improve mechanical advantage 2) “3 finger” grip to facilitate gentle blade placement and serial advancement 3) “5 finger” grip once blade tip in vallecula + ready to lift youtube.com/shorts/IclZ8... #EMIMCC

Vascular Access Hack: Convert small gauge IV in hand to large proximal IV 1) Place 22 gauge in hand 2) Place tourniquet above elbow 3) Infuse 25-50 cc of NS into small hand IV + wait 4) Proximal veins w/ plump up allowing larger IV placement proximally youtube.com/shorts/GvJ_T... #EMIMCC

👇 hard cosign on all this. And please, please, please, I'm on my knees begging you, please do NOT start a consult with the recitation of the comorbidities. "hi, I have an elderly man with a history of diabetes, hypertension, hyperlipidema, chronic low back pain, toenail fungus, tennis elbow..."

Calling a Good Consult -Introduce yourself/be polite -Start with the end: makes it clear to consultant why you are calling them. Follow w/ additional details. -Close the loop: ask about when they're gonna see patient + what else you can do to help youtube.com/shorts/-bYgs... #EMIMCC

Tact is the art of making a point without making an enemy. ISAAC NEWTON

Post-Intubation Sedation + Analgesia -Key:Call for your package when getting RSI meds so immediately ready -Propofol:Fast on, easy to titrate. Often get hypotension; add vasopressor -Analgesia important as pt undergoing painful procedures + tube itself is painful youtube.com/shorts/FGFix... #EMIMCC

Let’s Play Right Drug, Wrong Dose: Rocuronium Wrong: 0.6 mg/kg Right: 1.2 mg/kg Electricity in Cardioversion Wrong: start w/ 50J Right: start w/ max (200 J) Epi in Anaphylaxis Wrong: 0.3 - 0.5 mg IM Right: 0.5 mg IM - simplify decision in critical scenario youtube.com/shorts/nUTwH... #EMIMCC

Hyperangulated Video Laryngoscopy (HAVL) is all about curves + rotation -Blade placement, tube delivery + stylet removl are rotational -Pulling stylet straight out ➡️ tube dislodgement youtube.com/shorts/AY5-n... #EMIMCC

Opiate Toxicity + Reversal - Opiate toxicity causes hypoventilation. Need to follow RR + EtCO2 - O2 sat can mislead you to thinking all fine when pt w/ severe hypovent - Key to naloxone is to give the minimal dose necessary to reverse respiratory depression youtube.com/shorts/EvpZK... #EMIMCC

US in Cardiac Arrest Resus -ID treatable causes of arrest -Check peripheral perfusion -ID occult VF (ECG w/ non-shockable rhythm but US w/ VF) PMID: 40590825: 5.3% of cardiac arrests had occult VF Early application of US critical in arrest youtube.com/shorts/kR4Qj... #EMIMCC

K3tamine is fantastic for pain management -Particularly useful in patients w/ pain refractory to opiates or on chronic opiates (Oncologic pain, sickle cell disease) -Dose 0.1 - 0.3 mg/kg -Give as infusion to avoid perceptual disturbance youtube.com/shorts/59FI9... #EMIMCC

In skilled hands, bougie 1st = higher 1st pass success Does bougie 1st ➡️ more upper airway/tracheal injuries? Driver studies say no 2018 (PMID: 29800096) 400 in bougie arm, no injuries 2021 (PMID 34879143) 550 in bougie arm, no injuries youtube.com/shorts/Fnbor... #EMIMCC

Brisk trach bleeding = tracheoinnominate fistula Initial Management -Call vascular/CT surgery -Overinflate trach balloon to tamponade(works 85% of time) -Intubate, remove trach + place finger into stoma + compress innominate anteriorly youtube.com/shorts/Wxs-l... #EMIMCC

IO lines vital in management of critically ill 1)Use “1, 2, IO” approach: 2 shots at IV then IO. Ensures don’t waste time getting access 2)Prox humerus w/ better flow rates than prox tibia but must keep arm in internal rotation to avoid dislodgement/kinking youtube.com/shorts/EHtcU... #EMIMCC

K3tamine in peds PSA -No resp depression, no drop in BP Registry(PMID: 40481829): 13k peds PSAs -0.016% critical event rate (1 aspiration, 1 anaphylaxis) -0.52% high-risk event (mostly of need for BVM + brief apnea) -Laryngospasm: 7/13,000 youtube.com/shorts/aDUPR... #EMIMCC

Great thread and explanation

1/ 7th Day of Pharmacy Advent Let’s talk about anticoagulation in cirrhosis – a nuanced topic where balance is critical. Pts w/ ESLD face unique challenges d/t unpredictable pro- and anticoagulant changes. Let's dive deeper 👇 #medsky #pharmsky #GPsky #HMsky #emimcc #nursesky

PT virtually useless in assessing coagulation status in cirrhosis -Cirrhosis ➡️ abnormal synthetic fxn clotting factors + anticoags -Unlike w/ warfarin, lowering of factors isn’t uniform -Can have massive depletions in one factor + normal levels of others youtube.com/shorts/W51lW... #EMIMCC

Thanks for this post Anand!! 😊 Adding that atropine is often ineffective in BRASH. Epinephrine and isoproterenol usually needed for HR and perfusion support in severe cases #medsky #EMsky #emimcc #pharmsky

BRASH Syndrome: Bradycardia, Renal Failure, AV nodal blocker, Shock, HyperK AV nodal blocker + hyperK (even mild) w/ synergistic effects Treatment -Fluids if hypovolemic -Calcium for bradycardia -Epi in Hypotension (increases HR + shifts K) youtube.com/shorts/FqpV1... #EMIMCC

The Preloaded Bougie approach I prefer a 2 operator technique but good to have an alternate option in a pinch youtube.com/shorts/rrze5... #EMIMCC

The cognitive pause in refractory hypotension reminds us to stop, question our diagnosis + assumptions and consider alternate/additional pathologies - Acidosis - Hypothyroidism - Iatrogenic anaphylaxis - Hypocalcemia - Occult hemorrhage - RUSH Exam youtube.com/shorts/bvWoL... #EMIMCC

When patients don’t respond the way we expect, critical to take a cognitive pause + consider what we could be missing Stop focusing on a single unifying diagnosis Embrace Hickum’s dictum: “The patient can have as many diseases as they damn well please” youtube.com/shorts/AqvDD... #EMIMCC

Tiring vs Improving on NIV? RR drop can signal improvement or worsening Follow clinical status: improved mental status, more alert = NIV working Follow tidal volume: drop in RR + TV = worsening; drop in RR + incr in TV = NIV working youtube.com/shorts/mqqLZ... #EMIMCC

Advice for New Trainees #5: Never Lie. It’s not worth to tell what may seem like a small lie to cover up for something you forgot to check or do. Better to simply say, “I don’t know or I didn’t check. Let me find out and I’ll get back to you.” youtube.com/shorts/x6L6G... #EMIMCC

Hard cosign👇 Don't worry about looking smart, just focus on making sure the patients get the best possible care. And honestly that goes for everyone, all the time. This isn't about us, it's about getting the patients the best care. And if we need to look dumb to get that done, it's totally fine.