resident letting the first 10 drops of the lumbar puncture fall on the bed so they get a champaign tap

Insulin bolus typically not necessary in DKA but, consider if: Delay in getting insulin drip from pharamacy. Severe acidosis: reach therapeutic levels faster + fix the acidosis faster Bolus dose: 0.1 U/kg youtube.com/shorts/pYybS... #EMIMCC

this formula is clearly incorrect based on my high school science education you can't add a pressure and a velocity together because they have different units (mm, cm/s) if the units don't work, the formula must be invalid

it's wild how badly people dose hypertonic therapy 60 ml of 23% is equivalent to ~500 ml 3%, so this article makes no coherent sense best approach: figure out the sodium change you want and calculate the hypertonic dose math sets you free from dozens of contradictory consensus statements #EMIMCC

are you using a DEFCON-based strategy to manage bowel motility in hospitalized patients? having a clear, evidence-based treatment strategy improves efficacy & saves time you don't need to redesign the wheel for every patient & helpful to avert thermonuclear war emcrit.org/ibcc/constip... #EMIMCC

Fresh Blog: Mythbusting the use of beta-blockers for sinus tachycardia in thyroid storm This is one of the most dangerous & pervasive myths currently in circulation about acute care B-bl commonly precipitate shock or even arrest in these patients...(#1/2) blog: emcrit.org/pulmcrit/tst... #EMIMCC

@bradspellberg.bsky.social and other ID gurus - Does this look OK to you? Any critiques and/or additional thoughts you would pass along to front-line clinicians about implementing this regimen in real life? (disclosure: my hatred of ampho-induced AKI runs deep) emcrit.org/ibcc/cryptoc...

Updated the acute ischemic stroke chapter based on 2026 ASA/AHA guidelines Chapter focuses on supportive care (*not* who gets lysis/EVT) This has not changed very much Top blue numbered section is designed to be used as a checklist when you settle these pts into ICU emcrit.org/ibcc/ais/ #EMIMCC

The new 2026 AHA/ASA stroke guidelines include this table 👇 for the management of thrombolytic-induced angioedema. There is NO discussion or any additional text about this topic. I find this to be insufficient, not evidence-based, and potentially confusing... #1/2 #EMIMCC

#idboardreview 20 F cough, F, fatigue didnt improve w/azithro, no travel,+gardening: wbc 17k 90%pmn, Ct patchy nodules biopsy necrotizing granulomas stain+Aspergillus. Growing up, pt &her brother had several episodes of cervical lymphadenitis. How to make dx of possible genetic dz? #idsky #idmeded

Prolonged paralysis w/ rocuronium is an advantage -Once we decide to intubate, patient's getting tubed -W/sux, can end up in awake pt while trying to intubate if 1st/2nd attempt fail -W/ roc, plenty of time if you run into a challenging airway youtube.com/shorts/HXtN7... #EMIMCC

reminder to liberally check carbon monoxide levels during snowmageddon CO levels can be measured on venous blood along with routine labs (no need for a separate arterial puncture) emcrit.org/ibcc/co/ #EMIMCC

does anyone know of a good iphone digital pupillometry app that doesn't store data in the cloud (i.e., doesn't have patient confidentiality issues)?

end-stage academia: how to game the system to score more grants and publications this is ultimately a zero-sum rat race that doesn't help patients or science

🚨DCOS (delirium catatonia overlap syndrome) ~15% of critically ill delirious patients also have catatonia treatment is different from isolated delirium (e.g., antipsychotics can *exacerbate catatonia*) typical approaches to "delirium" are over-simplistic and mismanage these patients...(#1/2)

1/ Hello 👋 #medtwitter #neurotwitter #neurosky #medsky #neurocritcare #FOAMEd have another brief case that I wanted to discuss with you and see if maybe you can learn something new or reinforce old knowledge!

basically every single article on external ventricular drains ever written: neurology: "let us pontificate on the considerable bulk of data supporting rapid weaning strategies based on numerous outcome variables" neurosurgery: "go kick rocks"

Senator Bill Cassidy is virtue signaling about how he is a doctor and how deeply he cares about protecting the health of children.

antiseizure medications has a PK/PD profile similar to beta-lactam antibiotics: -efficacy relates to the trough level -toxicity relates to the peak level so benefit/risk ratio is maximized with smaller, frequent dosing hard to do outside the hospital re: adherence but easy to do for inpatients

just replace the first year of medical school with a one-year course in hostage negotiation

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)