first: combination inhaled epo + nitric simultaneously (I know its expensive, put it on my tab) epi gtt for MAP > 85 to improve cardiovascular reserve if the clot flies off then: 50 mg tPA (very little data on IR for clot in transit)

@pulmcrit.bsky.social hot take on RSI trial. Again, more questions than answers. But this editorial is amazing and gives you a different view on the trial amongst many other you're about to read in these days. #EMIMCC #FOAMed

No difference in mortality and such a big gap in CV outcome (surrogates). Something unmesured? #EMIMCC

updated the acute liver failure chapter biggest change is increasing support for early CRRT to remove NH3 (to reduce elevated intracranial pressure) now rec'd for clinically overt encephalopathy (Grade 2-4) if admitting to ICU for ALF & encephalopathy, just dialyze emcrit.org/ibcc/alf/ #EMIMCC

Not so fast with the capillary refill guided resuscitation (ANDROMEDA-SHOCK-2) #FOAMed

PPS - Bottom line is that if your critically unwell patient needs a CT scan you should just get the scan - Contrast-induced nephropathy is a myth emcrit.org/ibcc/contrast/ - Contrast allergy now just requires a dose of antihistamine - Radiation risks are minimal (especially for older adults)

DBP and pulse pressure are somewhat redundant. I added pulse pressure but they will generally trend in opposite directions provided the MAP is held in a somewhat fixed position around 70mm I guess the evaluation of congestion is kinda assumed... also I wanted to de-emphasize the whole fluids thing

"CRT, like a star, is not the destination but a guide for the journey". AS-2 it's not just a trial, it's a manifesto, an act of faith #EMIMCC #Andromeda #AndromedaShock2 #Sepsis criticalcarereviews.com/blog/current

ICU Snapshots: Young patient with multiple medical problems presented to ED for evaluation of "weakness". Decompensated; had to be intubated & placed on pressors (norepinephrine) before being transferred to our ICU

emcrit.org/pulmcrit/202... #EMIMCC Some @pulmcrit.bsky.social 's highlights about aha vs erc cardiac arrest guidelines #Emcritters

The 2025 European Resuscitation Council Guidelines have been released All 11 plus the executive summary included below CCR Journal Watch https://criticalcarereviews.com/latest-evidence/journal-watch

PLS SHARE. FOR PATIENTS SAFETY SAKE #EMIMCC www.tandfonline.com/doi/10.1080/...

ICU Practice - Return to Basics: When you prepare for the "average" intubation (no cardiac arrest, no active emesis), how do you pre-oxygenate the patient? Oxygen mask/nasal cannula? Non-invasive ventilation?

Give diuretics as boluses look at Chloride, k+ and pH Multimodal diuresis Not every form of "heart failure" need diuretics in the firsts hours #EMIMCC #DiuresisJedi #Deresuscitation

Had a case of elderly M with bilateral carotid stent intubated for sudden collapse and coma. CTA + CTP showed bilateral stent occlusion and complete shut down of anterior brain circulation. Signs of right upper limb ischemia (cold, pulseless). #EMIMCC #FOAMed #Stroke

A case in which V Tach should be prevented with adrenaline and chronotropism #EMIMCC

Those "softer" skills usually given for granted or misunderstood, "you have or you dont". In many place where I've trained or worked one spokes about leading as an abstraction and something you don't create or striving for #EMIMCC @emcases.bsky.social emergencymedicinecases.com/leadership-e...

5. Find a way to enjoy #EMIMCC @emcrit.bsky.social emcrit.org/emcrit/emcri...

Ketorolac coming at 30 mg per vial 🤯🤯🤯#EMIMCC

Tracheo emergencies toolbox #EMIMCC youtu.be/-2bFRCx0cFQ?...

If interested in ketamine for status, great debate emcrit.org/emcrit/ketam... @first10em.bsky.social vs @emcrit.bsky.social #EMIMCC

Cardioman, you re right, not a STEMI. But.. need the same care aka straight to the cath lab. Time to change paradigm #EMIMCC #OMI

It's entirely possible that bronchodilation is due to the anticholinergic and ketamine isn't doing anything. Regardless, I've used this combination (high dose ketamine + IV scheduled glycopyrrolate) and like the study shows it seems to work well. Pending further data this seems reasonable.🤷‍♂️

Mmmmm love ketamine but always I ve always been skeptical on super powerfull bronchodilatatory properties #EMIMCC

Keep your ED infusion pump for something else! #EMIMCC

Inspirational talk for EM DAY 27 may. Add yours . youtu.be/Au4L3H6oRaI?... . youtu.be/GFX_tocJShA?... . youtu.be/crjsmj4G0MU?... . emcrit.org/odr/should-m... #EMIMCC

We Debrief #Meu #EMIMCC #Simulation #Sim #Debriefing #HumanFactor #ZeroPointSurvey

Things we do for no reason. Kudos to @pulmcrit.bsky.social for the convertion model emcrit.org/pulmcrit/val... and PMID: 37989791 #EMIMCC #FOAMed

Ketamine instead of BZD #2? www.annemergmed.com/article/S019... #EMIMCC #FOAMed

Sometimes I wonder if it's a toxidrome. Above all this is how EM guidelines should be made, starting from the undifferentiated. I'd just add a section on human factors #EMIMCC #FOAMed #Toxidrome

For the #EMIMCC community some recent #FOAMed courses that I found very valuable: .THE BIG SICK 2025 (for the nerdiest) youtube.com/@tbszermatt?... .Emergency Cardiology Symposium and other #UMEM stuffs youtube.com/@umemergency... .Paediatric emergecies www.youtube.com/live/eWuXeD2... What else?

I think this aknowledgement should be spread for 2 important conseguences: 1)always use pocus to see the pump before starting high dose euglycemic insuline and 2)probably adding a pressor is needed #EMIMCC

And, sometimes, keeping antibiotics for a longer time may be helpful

ID Secrets: Are short antibiotic courses as good as long ones? Many times they are but please be aware of the fine details...

tricky focal sz with normal awareness (aka simple partial sz)- shouldn't cause neuro damage, no huge time pressure, discuss w neuro etc focal sz with impaired awareness (aka complex partial sz) - may cause brain damage but takes >60 min, so tx is similar to generalized convulsive status but slower

I recently took care of a pt with (known) focal seizures refractory to benzos...my doubt was whether to pull the trigger for ketamine, loading dose of antiepilectic med and how much aggressively treat the condition.. any pearl about it? #EMIMCC @pulmcrit.bsky.social

I think a good way is to debrief with good judgement, let the learner to search for ways to improve in a sort of maieutic method. Many times there's no wrong or right but there's a mental process that has to be vivisected to find the answer. This is my short thought on the topic #FOAMed #EMIMCC

as EM docs we'll always be looking after non sick patients. We hope the scissor between the very sick and not sick will be narrow in the future (letting other doctors to care for the not sick) but will not close for some years. Here's a tool to enjoy this part of the care emupdates.com/how/ #EMIMCC

The no false negative paradigm and why the revolution is so slow and many myocardiocytes have yet to perish uselessly #EMIMCC #OMI #STEMI

You are far more likely to permanently damage the spinal cord by allowing hypoxia and hypotension than you are by moving the patient. -Katie's second law

Collaboration in critical care airway management is a thing of beauty

super interesting! I boiled this down and simplifed/modified it to yield the summary below. I think we all do this to some extent but maybe should be more systematic about it. (and yes I'm publically admitting that I use femoral doppler instead of full VEXUS) (emcrit.org/ibcc/shock/#...) #EMIMCC

These data had been around for a while in various conferences, finally published. Is a must read for Prehospital and emergency medicine provider. #EMIMCC

pubmed.ncbi.nlm.nih.gov/38866231/ B-blockers may have a role in refractory/recurrent VF,truth is we don't know yet. I've heard strong opinion in favour, but at the moment we're harming our cardiac arrest patient (yes, even a dead one can be harmed) #EMIMCC

EMS / HEMS / prehospital EM Folks..Any protocol for noradrenaline infusion (without an infusion pump) in the prehospital setting? @cliffreid.bsky.social @ebmgonewild.bsky.social @sjtrem.bsky.social @stemlyns.bsky.social @emmanchester.bsky.social

What intervention between the two? PulseOx is not just a number #EMIMCC @pulmcrit.bsky.social @emcrit.bsky.social @imcrit.bsky.social

It's good the be an emcritter #EMIMCC

The Big Sick 2025 live stream??? #EMIMCC @emmanchester.bsky.social

c-collar repositioned correctly ✅

But Scott talk to me about LOGISTICS. 🧑‍🎓 This episode is a must listen #Emcritters #EMIMCC #IMEMCC @emcrit.bsky.social