updated the IBCC chapter on bradykinin-induced angioedema I think TXA or aminocaproic acid is an under-utilized & broad-spectrum agent (esp at centers without access to stuff like ecallantide) for best effect, probably need *repeated* dosing (not a single dose) chapter: emcrit.org/ibcc/angioed...

ACOG reaffirms that acetaminophen is safe for managing pain and fever during pregnancy. No reputable studies support suggestions like those in HHS’s recent announcement linking acetaminophen use in pregnancy to autism; in fact, high-quality studies show no such risk. https://bit.ly/47Wxc59

Joshua Faber (EM resident in NYC) created a chatbot designed to query the entire IBCC and link to relevant chapters This seems pretty neat to me Similar to AI in general, the specific answer may not always be correct, but it links to relevant chapters Thoughts? try it out: icbcc.onrender.com

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

hi, medical toxicologist that knows a lot about Tylenol here👋 Claiming that tylenol use in pregnancy causes autism is fearmongering here's what you need to know 🧵

proposal: all types of bradykinin-mediated angioedema involve a common vicious spiral 👇 tranexamic acid or aminocaproic acid should be universally effective in blocking this cycle & aborting attacks there's no need for super-expensive drugs (icatibant et al.) thoughts? criticism? #EMIMCC

"bUt tHe WhiTe cOuNT iS nOrmAL" I see this pattern of laboratory evaluation almost every day in the ICU anyone involved in evaluating acutely ill patients must be able to recognize this evolution, like the face of an old friend what is going on here? #EMIMCC 🧵 #1/5

EMCrit 1:1 Nursing 005 - Medical Cardiac Arrest. Candice and I discuss: - The Nurse Code Leader - Prebrief/Debrief -Holding Mech CPR Hostage and so much more!!! [#FOAMed for now] emcrit.org/1to1-005

#idboardreview 16 M fever, progressive neck swelling (bull neck), nasal regurgitation of food, progressive dyspnea, orthopnea. Pharynx/tonsil w/ gray membrane. EKG with heart block. Isolation precautions? duration of precautions? #medEd #idmedEd #idsky #IPsky

updated IBCC chapter on anaphylaxis, some new additions: 🆕 methylene blue for anaphylaxis refractory to epi & fluid 🆕 sugammadex for anaphylaxis 2/2 roc or vec 🆕 nebulized epi (in combination with IV) for upper airway edema? Don't bank on it but might help? (emcrit.org/ibcc/anaphyl...) #EMIMCC

COVID vaccine can now be given by pharmacists to anyone >5YO without a prescription in Vermont 👏 Per order of Gov Phil Scott & the Vermont DOH This obviously makes a ton of sense, especially for VT Closure of beds in rural hospitals leaves our state with few extra staffed beds in the winter

Short skytorial about a fresh IBCC chapter covering all things methylxanthine-related (caffeine & theophylline). This is a niche topic that we don't encounter in everyday practice, but it ties together some loose ends. (chapter is here: emcrit.org/ibcc/caffeine/) #EMIMCC

🌟 ABX Pearl of the Day: ❓ Q: My patient is growing yeast in blood cultures. Is this Candida? #IDsky #medsky #meded #pharmsky #skyRX #AMSsky

1/ 👋 there #neurotwitter #neurocritcare, as part of my @neurocritcarej #SoMeAmbassador role, today we will be breaking down the following article:

Our society is dangerously obsessed with super-rich people and celebrity. Seriously, we need to stop taking health advice from eccentric billionaires and actors.

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)

many people don't know what an "attending" is; the term "supervising ICU doctor" may be less ambiguous but be careful about rolling in like the big honcho, because then folks may devalue the resident & fellow (when trainees are doing an amazing job & better positioned to answer many questions)

this story is wild 🤡 “This did not clearly meet traditional standards for statistical significance. However, a bayesian design was employed, which provides flexibility for investigators to produce favorable results.”

Fresh IBCC chapter: Cannabis use & complications 🌿 Legalization, higher %THC products, & edibles are making this an increasingly common issue 🌿 Cannabis withdrawal is an overlooked cause of misery & patient-directed discharges 🌿 Cannabinoid hyperemesis syndrome emcrit.org/ibcc/cannabis/ #EMIMCC

just added a new section on RIC lines (rapid infusion catheters) to the IBCC a RIC line basically involves up-sizing an 18-20G PIV to a 13G PIV using a Seldinger technique we just got these, so I'd love to hear folks' opinions on them & any pearls/pitfalls #EMIMCC emcrit.org/ibcc/mtp/#ra...

gram negative rods *rarely* cause blood culture contamination so a single blood culture growing gram-negative rods should generally be regarded as real & treated as such (this is *unlike* GPCs, where one culture is often a false-positive due to skin organisms like coag neg staph) #EMIMCC

EMCrit 408 - Behind the Scenes of an Infuriating Medical Malpractice Trial. I am joined by @medmalreviewer to discuss the case and then in a true surprise-the Jury Foreperson weighs in. @embouncebacks @GitaPensaMD [#FOAMed for Now] emcrit.org/408

Droperidol vs haloperidol: what is the fairest butyrophenone of them all? This is largely based on receptor affinity rather than RCT data Mechanistically, droperidol has more multimodality elegance, whereas haloperidol is a D2-receptor blocking hammer Thoughts? emcrit.org/ibcc/deliriu... #EMIMCC

For anyone wondering whether to get the COVID vaccine: You can & should trust the American Association of Pediatrics & the American Academy of Family Physicians. These are among the most hardworking, underpaid, evidence-based, and well-intentioned doctors out there.

Left: Lungs on fire due to EVALI Right: Fire extinguished s/p steroid Follow me for more wisdom on pulmonary pathophysiology.

Cutting healthcare for anyone will impact on everyone. We're all in this public health boat together. #EverythingIsTuberculosis

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

this is my take on propranolol as a sedative 👇 I've done this and would welcome more data supporting it but currently evidence is weak, so it's a niche application (esp for patients who need a beta-blocker for other reasons) data for alpha-2 agonists (clonidine, guanfacine) is more robust #EMIMCC

this TWDFNR article is accurate and good. but, understanding the physiology of how to convert a VBG to an ABG is a more generalizable and powerful approach to this problem more here: [1] initial study: emcrit.org/pulmcrit/vbg... [2] international validation study emcrit.org/pulmcrit/val...

I can't help but feel some dread for this coming winter in the ICU. For the 1st time (as far as I know), our gov't (RFK, Jr in HHS) is spreading misinformation about the benefits of vaccines. I re-read an old essay I wrote and hope that I will be again, Brave Enough.

Nalbuphine is the Diet Coke of opioids: fresh blog 🥤 Multimodal mechanism of action: partial mu-opioid agonist (like buprenorphine) & kappa-opioid agonist 🥤 Reduced incidence of mu-opioid agonist side-effects (respiratory suppression, emesis, abuse potential) emcrit.org/pulmcrit/nal... #EMIMCC

super important point 👇 sometimes creatinine falls due to dilution from large-volume fluid resuscitation. if the urine output is zero then the GFR must be zero (regardless of how much the creatinine has decreased).

Percutaneous cholecystostomy drain for acute cholecystitis: The evidence is VERY weak If someone is deteriorating with refractory septic shock, then drain it If the patient is responding to medical tx, then there is no need to place a tube.... 🧵 #1/3 pubmed.ncbi.nlm.nih.gov/40900585/ #EMIMCC

for frontline healthcare workers who soldiered through COVID, it’s re-traumatizing to go through this same BS again - with Trump et al. once again trivializing the disease, gaslighting physicians, and embracing antivax idiocy. 😞

your chances of getting malignant hyperthermia from succinylcholine is low, but never zero

new IBCC section on diphenhydramine toxicity 😁 ☠️ very common ☠️ can be severe ☠️ management can get complex (hybrid of anticholinergic tox & Na-blocker tox) would be interested in any feedback on this (like all things toxicological, there's not a ton of data) emcrit.org/ibcc/anticho... #EMIMCC

1/ Hello #medsky #neurosky #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!

I would add that fomepizole, in addition to inhibiting CYP2E1, blocks the cascade of increasing oxidative damage that eventually leads to hepatocyte death. This suggests fomepizole may add benefit even when the acetaminophen level is low or undetectable and there's no more drug left to metabolize.

Updated the acetaminophen toxicity chapter based on 2023 guidelines. These are solid guidelines by multiple 🇺🇸 & 🇨🇦 tox societies. The guidelines clarified some grey areas, allowing the chapter to be a lot crisper. Also added fomepizole for high-risk ingestions 😁 emcrit.org/ibcc/acetami... #EMIMCC

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?

this is useful information, but... if you have an ED patient who clearly requires ICU (e.g., ICP elevation, critical asthma) don't delay calling us 👋 getting on board early can help expedite logistic stuff & smooth out the transfer process also, walking down to the ED helps me get my steps in

Irony: an article about the drawbacks of publication in medical journals is... buried behind a paywall. It's stupid the way journals paywall editorials. My guess is that opening up free access to editorials would, if anything, *increase* interest in the journal and increase subscribers.

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...

Triple-threat strategy for using LLMs to answer a medical question: 3️⃣ Have your own opinion & use conventional sources 3️⃣ Narrow-spectrum LLM (OpenEvidence) looks at highest quality sources, but has blinders 3️⃣ Broad-spectrum LLM gives 3rd opinion fresh tiny blog emcrit.org/pulmcrit/tri... #EMIMCC

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

☝️DIGIT trial shows benefit from digitoxin in HFrEF (even in context of reasonable GDMT) numerous limitations but consistent w/ the seminal DIG trial (👇 hospitalizations) digitoxin is hepatically metabolized making dosing easier (not available in USA) #1/2 #EMIMCC www.medscape.com/viewarticle/...

scout images for CT scans are hidden gold the scout often gives you high-resolution images of a LOT of the body (FAR beyond the body part getting the CT scan) for example, the scout of a CT C-spine may be great to confirm ET tube position #EMIMCC

agitation alone is usually not a reason to keep a patient intubated *extubation* usually improves the agitation a lot (often resolves completely off vent) if otherwise ready for extubation: extubate, reassess off the vent, treat any residual agitation PRN #CowboyExtubation #AlwaysBeExtubating

These states have fantastic health departments. LFG

Global warming is increasing the rate of Vibrio vulnificus infections in Louisiana and Florida. Also, the CDC has stopped tracking Vibrio infections. So basically, don't eat any oysters 🤷‍♂️ www.nbcnews.com/news/us-news... #IDsky