🚨 Follow up post to my review of HI-PEITHO. ​Does catheter directed Thrombolysis actually work? STRATIFY Trial suggests CDT doesn't work. 🧵👇 #MedSky #CritCare #FOAMed #emimcc

🚨 Intermediate-high risk PE: RV strain + troponin. Stable for now, but will they crash? ​HI-PEITHO (NEJM 2026) finally gives us RCT data for Catheter-Directed Lysis (USCDT). Is this the new standard for the "sickest of the stable"? 🧵👇 #MedSky #CritCare #FOAMed #emimcc

I showed this graph in class yesterday on how measles cases in the United States plummeted dramatically after the vaccine was licensed in 1963. It’s not subtle and I could not resist observing: “This stunning design in measles cases was not thanks to vitamin A. It was not due to beef tallow.”

It's quite shocking the practice differences between SICU and MICU even for overlapping conditions.

​🚨 New Trial: TIGRIS 🚨 Polymyxin B Hemoadsorption (PMX) in endotoxic septic shock. ✅ 99.4% probability of benefit for 90-day survival. ✅ 15.5% absolute risk reduction in mortality. ✅ NNT of 6.5 ​Interesting step towards endotyping shock and immune mediated management.🧬 #FOAMed #emimcc #critcare

Patient with cardiogenic shock, EF <10%. Micro axial flow device is placed. Is there loss of the Windkessel effect due to the micro axial device? #emimcc #critcare #FOAMed #Physiology

Following up on the HD-CPR post: here is Per Olav Berve at Big Sick 2018 explaining exactly why monitors lie to us during mechanical CPR. If you want to understand "pre-tidal" CO2 and true diastolic pressure, watch this. ​ #CritCare #FOAMed #emimcc

Hemodynamic-directed CPR question for everyone: If you have an A-line during arrest and compressions are generating a dBP >30-40 mmHg, do you consider holding ACLS epi pushes? Curious who is individualizing CPR here. #CritCare

We are moving more and more into an individualized shock management era and POCUS is leading the way. I've been working on incorporating the interfaces model and estimating Ea/Ees for ventricular arterial uncoupling. #FOAMED #CritCare #POCUSsky

🚨 Septic shock, AKI, pH 7.15. Do you start a Bicarb drip? Does it save kidneys or just treat a number? I built an open-access "Landmark ICU Trials" cheat sheet/reference for rounds. Let's look at a new addition: BICARICU-2. 👇 #MedSky #CritCare #Nephrology #FOAMed #MedEd

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…

New ESICM guidelines on circulatory shock. www.esicm.org/esicm-guidel...

New RCT: Avoiding A-line in shock didn't affect mortality (trend towards *reduction*) & decreased line complications They avoided A-lines despite patients requiring pretty substantial doses of vasopressors Very #zentensivist Don't need to rush to an A-line www.nejm.org/doi/full/10.... #EMIMCC

Andromeda Shock 2 Trial is out.

Decay in Physiologic Knowledge Since Med School Among Critical Care Fellows 1st-yr PCCM/CCM fellows perform worse than med students on assessment of pulmonary physiologic concepts, suggests decay in knowledge during training @atscommunity.bsky.social #medsky tinyurl.com/tfwutc76

A good review of the furosemide stress test. www.mdpi.com/2077-0383/14...

Have been learning about hemodynamic coupling, currently reviewing interface IV (RV-PA coupling). This is a great review article on RV failure. pmc.ncbi.nlm.nih.gov/articles/PMC...

is contrast nephropathy in the room with us right now? another article showing that contrast nephropathy isn’t a thing I wonder how long these articles will keep getting published, since I kinda thought this was settled 🤷‍♂️ https://www.jem-journal.com/article/S0736-4679(24)00372-X/abstract #EMIMCC

1/ One of the BIGGEST #POCUS misconceptions is that B lines 🟰 pulmonary edema 🤦‍♀️ Did you know that there is actually a wide DDx for B lines? Check out my latest video about #LungUltrasound for interstitial syndromes 👀; or read on for the highlights 👇 🧵 #emimcc www.youtube.com/watch?v=eSuA...

Been doing some reading and listening on advanced resuscitation/hemodynamics. Dr. Per Olav Berve gave a fantastic lecture at the Big Sick in 2018. Takeaways: 1. Diastolic BP goal > 25 using late diastolic peak on A-line 2. EtCo2 monitoring during code, use the peak alveolar plateau readings.

How does everyone feel about the Peerless trial?

Sometimes we get so wrapped up in aggressive management and intervention. I think early palliative care discussions are really important for the patient, their family, and for us. The idea of zentensive care fits well with this. Less is more.

ICU Case Discussion: Part 1 Young patient presents with AMS, found with numerous empty pill bottles including NSAIDs, muscles relaxants, and metformin. Lactic acid >15 mmol/L. pH 6.9. Kussmaul breathing. Suspicion of metformin overdose. What is everyone's fluid of choice? #CriticalCare #ICU

1/ Back to the basics today: let's talk about common pitfalls in obtaining cardiac #POCUS images ❤️ Here are some very common image acquisition errors in basic views, as well as the simple moves to correct them ✅ 🧵 #emimcc #POCUSky #echosky #MedSky

Optimist: The cup is half full Pessimist: The cup is half empty Intensivist: We need VEXUS to determine how congested this cup really is. #icusky #medsky

Optimist: The cup is half full Pessimist: The cup is half empty Pragmatist: There’s an IV fluid shortage, the cup’s volume status is fine.

Now seems like a good time to remember that #vaccines are the greatest #publichealth intervention in history, saving 154 million lives in the 50 years since the start of the Expanded Programme on Immunization in 1974. #EpiSky #IDSky #PedsIDSky doi.org/10.1016/S014...

A few days ago we talked about different types of shock, including obstructive shock. This is a great article on acute PE risk stratification and it includes some helpful diagrams. #Medsky #CriticalCare #ICU #CriticalCareMedicine

Slow correction of hyponatremia associated with increased mortality. Interested to hear how everyone feels about these findings.

I'm on nights this month and always struggle with switching back and forth. Anyone have any tips for successfully switching back to days? I've thought about trying bright light therapy.

Ultrasound has to be one of the greatest tools in an intensivists arsenal. So many questions can be answered with it. Echo, vexus, VTI, I love it all.

Working on putting together a post on my approach to undifferentiated shock. Stay tuned.

Case discussion: Patient is admitted with right lower extremity compartment syndrome and profound shock requiring max dosing on 4 vasopressors. Too unstable for OR. After discussions with surgical team, opted to perform a Cryoamputation. The patient's leg is demarcated and covered in dry ice.

Lets talk about ARDS. Amato, M. B. P., Meade, M. O., Slutsky, A. S., Brochard, L., Costa, E. L. V., Schoenfeld, D. A., ... & Network, O. S. S. (2015). Driving pressure and survival in the acute respiratory distress syndrome. The New England journal of medicine, 372(8), 1 747-755.

Just had our difficult airway training session as well as Minnesota tube placement. Almost immediately got the chance to employ my new skills. Do you guys tend to use traditional three way stop cock or Lopez valves with your Minnesota tubes?

Disease prevalence in US states before & after vaccine introduction Graphic from Edward Tufte More graphics.wsj.com/infectious-d... 🧪

One of my favorite @criticalcaretime.bsky.social infographics: Comparison of vasodilator scavengers. When to choose 🟦 Methylene Blue 🟥 Hydroxocobalamin (Cyanokit) For more discussion you can read here: onepagericu.com/blog/mini-le...