I will be overhauling the neurology IBCC chapters this year if you have any great review articles or books that I should include, let me know

updated the IBCC chapter on BRASH added a treatment checklist that walks you through resus of a sick BRASH pt BRASH is uncommon & there are lots of moving pieces, so the checklist is a helpful cue to provide comprehensive treatment of all the BRASH components emcrit.org/ibcc/brash/ #EMIMCC

IBCC service update: Checklists are being converted to numbered grey subsections These are intended to function as a checklist to guide real-time patient management Advantages: ☑️easier to read on phone ☑️more flexible (can include images/links) ☑️can be read & used by LLMs

New York state just recorded the highest number of flu cases in a week since it started recording in 2004. 😳 This includes the 2009 H1N1 pandemic (I was a pulm fellow in NY then and it wasn't a great time).

has there ever been a high-quality RCT that demonstrated clinically meaningful benefits from pulse-dose steroid (e.g., 500-1000 mg/day methylprednisolone) as compared to a moderate dose of steroid (e.g., 1-2 mg/kg/day prednisone)? for *any* disease?

ordering a troponin, BNP, lactate, CRP, iCal, EEG, D-dimer, and panculture on a stable, long-stay ICU patient 5 minutes before your shift is over

interesting piece on gabapentin overutilization thoughts [1] gabapentin withdrawal is real; don't stop it cold turkey [2] gabapentin is renally cleared; accumulation 2/2 AKI is a common cause of hypoactive delirium [3] pregabalin has superior pharmacokinetics www.msn.com/en-us/health... #EMIMCC

D-dimer in PE: High false pos rate at standard thresholds -Age-adjust(PMID: 24439717) + YEARS(PMID 28549662) incr threshold w/o incr miss rate -Lancet Study(PMID: 41135553) simplifies: If PE isn’t most likely dx, double threshold -0% miss rate w/ 19% decr CT youtube.com/shorts/rfXcN... #EMIMCC

Holiday gift for ya: the IBCC chatbot app 😁 Free AI chatbot searches IBCC contents Answers seem pretty good & it links to relevent chapters for additional info Works as an Ebook index on steroids Created by emergency med folks at Columbia (credit to Joshua Farber & David Fisher) #EMIMCC

I sometimes see folks recommending neuro checks for patients with neuromuscular disease (e.g., Guillain-Barre, myasthenia gravis) this makes no sense to me is there something I'm missing? why would you do neurochecks for a neuromuscular disorder that doesn't involve the CNS? #EMIMCC

everyone predicting the end of medicine due to artificial intelligence 🙄

Hypotension + Bradycardia: Updated Differential -HyperK -Beta blocker/CCB tox (can occur outside overdose) -Clonidine or digoxin tox -Blood in belly (vagal stim) -Neurogenic shock -Severe hypothyroid -HyperMg -Inferior MI -Advanced AV blocks -BRASH Syndrome youtube.com/shorts/S3ibt... #EMIMCC

Should we routinely provide fiber w/ enteral nutrition for critically ill patients? Data is hard to interpret 2/2 variable treatments But available RCTs suggest it's safe & beneficial May support enterocytes & maintain microbiome Giving a zero-fiber diet never made physiological sense #EMIMCC

RSI Trial(PMID:41369227): Etomidate vs Ketamine -No diff 28d mortality -Incr HD collapse w/ ketamine (driven by incr/new pressors) -Not clear why (More aggressive resus in etomidate group?) -Forces us to reconsider our induction agent choice youtube.com/shorts/CFWOR... #EMIMCC

The CDC has approved ending blanket recommendations for HBV vax at birth 😩 Will hurt people & increase healthcare costs Whether you care about humans or stocks, this is obviously dumb Vaccination = huge return on financial investment Healthy workforce = 🤑 Need to make this case to finance bros

if fentanyl is a weapon of mass destruction, I guess that makes me….. Dr. Evil?? RELEASE THE FENTANYL

Does coffee lead to atrial fibrillation | The DECAF trial You are at a conference. You had 1 glass of wine too many last night, so you had to add an extra coffee to get moving this morning. Then you feel a slight flutter in your chest. Caffeine is a stimulant, right? Could it be causing atrial…

sedationists - any critique on this checklist for MidaKet procedural sedation? basic explanation for MidaKet here: emcrit.org/pulmcrit/mid... I'm usually using this for EGD, but many other uses we often don't take EGD sedation too seriously, but a little extra care can avoid disaster #EMIMCC

1st, I review the resident note: it’s disorganized but OK 2nd, I review the med list. Every drug is perfectly dosed, timed, and routed. Totally optimized, tidy med list.

go home pharma, you’re drunk

Pericardial Tamponade: fix is drainage but resus prior focuses on full, fast + squeezed #1: Full: Volume expansion #2: Fast: Tachycardia helpful as increases cardiac output #3: Squeezed: Use vasoactives to ensure adequate SVR + contractility (epi if bradycardic) youtube.com/shorts/2Yth1... #EMIMCC

when I use etomidate, I generally add fentanyl (analgesia) & midaz (prolongs sedation >5 min & reduces risk of awareness) I wonder what the BP difference is between ketamine vs an etomidate-midaz-fent cocktail?? 🤔 my guess would be: not much don’t use pain as a pressor

End of an era, you will not be missed

Inpatient pharm pearl: Infusion durations for IV iron & bisphosphonates were designed to be *short* to improve patient throughput at *outpatient* infusion centers For inpatients, SLOWING DOWN the infusion reduces infusion reactions/toxicity with *same* efficacy (these drugs work slowly) #EMIMCC

IMO ketamine unmasks instability due to the analgesic effect. Folks who forget that and think the inotropic effects will dominate get nasty surprises in catechol depleted patients. I don’t use etomidate at all anymore except in florid HF.

🔥Fresh blog🔥 Hot take on RSI trial of ketamine vs etomidate RSI & EvK trials both show *more* BP instability with ketamine *but* lower mortality with ketamine 🤔 Cause of BP drops with ketamine? - Less pressor pre-intubation? - Ketamine provides analgesia (eliminating pain-as-a-pressor)? ... #1/2

ferritin hipster: writing about anakinra for hyperinflammatory sepsis phenotypes before it was cool this is from 2016 emcrit.org/pulmcrit/sep...

neurosurg: WHAT IS THE GCS? me:

this is accurate and important, but it should be a *discussion* between ID and the ICU team it drives me batty when the ID service recommends changing antibiotics to avoid excess sodium administration usually best for ID to rec the best antibiotic. I'll diurese the patient as needed. #diuresisjedi

updating the IBCC chapter on ECMO any recent advances or important articles I should include? please share any recent practice-changing insights you’ve had about ECMO 🙏 (it’s one of the harder chapters to update due to high volume of new research)

this article is so unserious it feels satirical whole-body MRI scans for worried well are horrifically low-value they find incidentalomas, leading to downstream costs & iatrogenic harm not sure what it's doing in a newspaper (if that's what we're calling the WaPo) www.yahoo.com/lifestyle/ar...

there are three times more articles on lung cancer screening than smoking cessation interest in lung cancer screening continues to rise, while publications on tobacco cessation are falling over time

Prasad just got a 95% BSA 3rd degree burn in the NEJM 🍿

anaphylaxis to rocuronium can be treated with sugammadex. this is simple and really neat. anaphylaxis to sugammadex is more complicated: 😁 if rxn to sugammadex *alone* --> giving roc will make things BETTER 😫 if rxn to [sugammdex-roc] *complex* --> giving roc will make things WORSE #EMIMCC

in thyroid storm, treating sinus tach w/ a beta-blocker will occasionally cause death many patients have reduced LVEF & compensatory tachycardia (borderline cardiogenic shock) beta-blockers push them over the edge what data supports B-bl in thyroid storm? could we please stop doing this? #EMIMCC

Prasad spent the pandemic braying about EBM & the "need" for RCTs to show that masks work Now he's changing FDA policy based on a few old VAERS reports of dubious veracity This is unhinged (And anyone who actually cared about saving kids' lives would focus on measles & pertussis vax rates)

treatment of severe/refractory hypoglycemia (IBCC update) commonly messed up in practice & literature 🤦‍♂️ key points: 🧃 IV dextrose gtts are good but not super effective 🧃 PO carbs are more effective 🧃 IV steroid for refractory dz 🧃 structured escalation 🧃 rarely needs ICU admit #EMIMCC

EMCrit 413 - Translating Recent Sepsis Papers to the Bedside with @PulmCrit (Farkas) - Confounding Effects of Vasopressin - Perfusion Index? - Echo-Pressor-Echo & so much more... [#FOAMed for now] emcrit.org/413

updated IBCC chapter on severe influenza most notable updates are on the pharmacology of newer antivirals (peramavir & baloxavir) oseltamavir remains 1st line for patients without contraindications (yeap, data on these isn't great, but we're stuck with them) emcrit.org/ibcc/influen... #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

Patient with cirrhosis and INR of 3 needs a procedure Please step away from the FFP EVERY guideline & article agrees that FFP shouldn't be given for pre-procedure coag optimization (even high-risk procedures) Plt & fibrinogen are more controversial Discussion emcrit.org/ibcc/cirrhos... #EMIMCC

1/ Happy 🦃 day #neurotwitter #neurosky #neurocritcare. Before your postprandial somnolence kicks in, wanted to talk about 🩸 transfusion parameters and break down the following article:

would not start antihypertensives. would discharge home immediately (it doesn’t seem like this admission is even indicated?) outpatient followup honestly this guy needs good outpatient management, not a fancy hospitalization that will be super expensive

Trimethoprim-sulfamethoxazole carries a very low (but real) risk of causing ARDS. Duration of therapy is a risk factor (>7 days). Could likely be minimized by avoiding unnecessarily long courses. TMP-SMX is usually well tolerated, but can wreak havok (SJS, ARDS, drug-induced meningitis). #EMIMCC

“I have been using a combination of cap refill and MAP since the original ANDROMEDA SHOCK paper” Justin explores the many limitations of this trial but then admits that he does use CRT as a resus target. I fundamentally agree. Implementing imperfect data into practice is complicated. #EMIMCC

New study design: Multiply a small & uncertain number with a big number and you get a big number The final big number looks, well, really big This grabs headlines & gets cited It doesn’t clarify underlying uncertainty, so it doesn’t actually illuminate anything Mathematically rigorous clickbait

ADQI/ICA guidelines finally scrapped the 48-hour mandatory albumin infusion before formally diagnosing HRS-AKI I’ve argued against this for years (it delays tx for 3 days & you miss optimal window for intervention) HRS-AKI carries a massive ~30% in-hospital mortality, its an emergency…

patients w/ hepatic encephalopathy sometimes develop a spontaneous portosystemic shunt (their body essentially creates a TIPS) that exacerbates encephalopathy if they are healthy enough to tolerate closure (MELD <11), IR ligation of the shunt improves encephalopathy this case👇 is extremely unusual

a fancy nephrology guideline trying to describe how to titrate a norepi gtt is sending me 🤣 adjust q4hr?? the whole point of a NE gtt in HRS-AKI is immediate BP control tell the ICU RN the target MAP and they will achieve it immediately... that's why NE gtts are great (and peripheral IV is fine)

Ethical review of brain death in the context of familial objections or pregnancy. This is largely intuitive and common sense, but it's useful to have a guideline if needed for reference. #EMIMCC www.neurology.org/doi/pdf/10.1...