Plea from an intensivist: Don't use ACEi/ARB for management of HTN in patients who are tenuous or have limited prognosis (eg advanced malignancy). There are much safer anti-HTN tx's (amlodipine, nifedipine XR). Educate patients that if they're too sick to eat they should to hold ACEi/ARB #EMIMCC

Contrast may cause anaphylacTOID reactions (not anaphyLAXIS) (anaphylactoid rxns = angry mast cells spit out histamine; usually less severe than anaphylaxis) Canadian guidelines: don't pre-treatment w/ steroid, give antihistamine This makes physiological sense! Thank you science! #1/3. #EMIMCC

1/ Newer data is reshaping post-MI β-blocker strategy. REBOOT shows no benefit when EF>40% in patients receiving modern invasive/medical therapy, while pooled data from BETAMI, DANBLOCK, and CAPITAL-RCT suggest benefit in the EF 40–49% range. #medsky #pharmsky #emimcc #cardiosky

there's been LOTS of back-and-forth about vaso in sepsis (e.g., these two 2025 review articles reach totally different conclusions! Lajoye is correct IMHO) TLDR: there is no simple answer; personalize tx 🌌 my current take on vaso in sepsis is here: emcrit.org/ibcc/shock/#... #EMIMCC

1/ Newer data is reshaping post-MI β-blocker strategy. REBOOT shows no benefit when EF>40% in patients receiving modern invasive/medical therapy, while pooled data from BETAMI, DANBLOCK, and CAPITAL-RCT suggest benefit in the EF 40–49% range. #medsky #pharmsky #emimcc #cardiosky

Fascinating paper suggesting the assumption that there is a sigmoid dose response relationship and threshold effect ( "all-or-nothing") for loop diuretics rests on repeated misinterpretation of original studies from the 70s and 80s. #nephsky #cardiosky #emimcc academic.oup.com/ehjcvp/artic...

Nothing normal about “normal” saline -0.9% NaCl: 154 mEq Na + 154 mEq Cl. pH ~ 5.6 -Human/animal data shows it's proinflammatory -SALT-ED (PMID:29485926) + SMART (PMID:29485925) show incr kidney injury w/ 0.9% NaCl vs balanced solutions -LR more physiologic youtube.com/shorts/XcV7R... #EMIMCC

Incr safe apneic time important in improving 1st pass success -Preox w/ NIV: Incr PaO2, recruit alveoli -Oxygenate + intubate in Bed Up, Head Elevated -Apneic O2 w/ flush rate NC -Use rocuronium instead of succinylcholine (up to 45 sec more safe apneic time) youtube.com/shorts/-3MFR... #EMIMCC

Endovasc Stroke Tx + Airway -High risk airway decomp: High NIHSS, AMS or Posterior Stroke -Etomidate a great agent: HD stable -Avoid hypocarbia (cerebral vasoconstriction) -After intubation, lie patient flat. Studies (PMID: 40465238) show improved outcomes youtube.com/shorts/LChtQ... #EMIMCC

Inspired by @pulmcrit.bsky.social’s recent post on PCN allergies! Thought I’d repost a skeetorial on PCN allergies to add to the great discussion. Link below: bsky.app/profile/alau... #medsky #pharmsky #EMsky #RNsky #GPsky #FOAMed #EMIMCC #IDsky

Intubating in elevated ICP -BP control w/ clevidipine/nicardipine -Fentanyl: blunt catechol response -Osmotic agents: 30 cc of 23.4% hypertonic -Etomidate + rocuronium (no fasciculations, longer safe apneic time) -Sedation/analgesia ready(bucking tube spikes ICP) youtube.com/shorts/747a9... #EMIMCC

Largest ever study of peripheral 23.4% NaCl with 863 administrations 😀 Some extravasation did occur, but it *didn't* lead to any major problems (tissue necrosis etc) If someone is having an ICP crisis, you should worry about their BRAIN and not their ARM - their arm will be fine #EMIMCC

I continue to be shocked by how PCN allergies are misunderstood This is from UpToDate on neutropenic fever It's wrong With PCN allergy, you can absolutely use cefepime, piptazo, or meropenem The R-chain structure that determines allergy is different emcrit.org/ibcc/penicil... #EMIMCC #IDsky

For #criticallyill patients who had both severe metabolic acidemia and moderate to severe acute kidney injury, sodium bicarbonate therapy did not significantly decrease day 90 all-cause mortality. #LIVES2025 @esicm.bsky.social ja.ma/3Ll9Exv

The BICAR-ICU-2 trial just dropped! RCT involving IV bicarb in metabolic acidosis among patients with mod-severe AKI Bicarb didn't affect mortality but it reduced the need for dialysis & risk of bacteremia VERY similar conclusions to BICAR-ICU-1 🧵 #1/ jamanetwork.com/journals/jam... #EMIMCC

MASSIVE RCT from Kenya showing that steroids reduce mortality in CAP Mortality benefit easier to demonstrate w/ less resources available to salvage pts Should allay the hype that the negative REMAP-CAP steroid RCT received (despite being woefully underpowered) www.nejm.org/doi/pdf/10.1... #EMIMCC

unpopular opinion: if ICP is unequivocally elevated due to cardiac arrest (eg >25mm), that suggests severe brain injury with a poor prognosis, no matter what you do. this explains why trials of higher MAP targets after cardiac arrest (eg BOX trial) are all neutral. #EMIMCC

Bed-Up-Head-Elevated (BUHE) positioning is an easy, effective way to increase safe apneic time and reduce intubation related complications PMID: 26866753 youtube.com/shorts/BnZz0... #EMIMCC

CDI recurrence affects about 14% to 16% of patients with CDI, and the risk of recurrence increases with each CDI episode 🆕💫🌟 JAMA Insights Recurrent Clostridioides difficile Infections 🟢Epidemiology and Risk factors 🟢Diagnosis 🟢Treatment #IDSky #EMIMCC jamanetwork.com/journals/jam...

Wow! This is pretty innovative!! 🤯

DKA Tip #3: HypoK the big killer -All DKA patients total body K depleted -Some p/w hyperK due to acidosis shifting K -K < 3.5, replete prior to starting insulin. > 3.5 start insulin + K together -Skip bolus: no faster resolution of DKA but incr risk of hypoK youtube.com/shorts/PK_qF... #EMIMCC

DKA Tip #2: Urine dip can mislead -Body produces 3 ketones: acetoacetate, acetone + beta hydroxybutarate (BHB0 -UA only looks for acetoacetate. BHB dominates in early in DKA -If worried about DKA, get a chem/blood gas for bicarb + pH + serum BHB youtube.com/shorts/3KnuI... #EMIMCC

Hot take: You WANT the #creatinine to go up while diuresing in #cardiorenal syndrome AKI. It’ll come back down when they’re better. It’s a feature, not a bug. #Medsky #Nephsky #cardiosky #cardiology #criticalcare @pulmcrit.bsky.social @imcrit.bsky.social #AKI #heartfailure #diuresis

Role of insulin in DKA isn’t to drop sugar, it’s to shut of ketogenesis + close AG -Don't stop insulin just because glucose hits 250 mg/dl -Stop when AG closes, acidosis mainly resolved (bicarb greater than 18), long acting insulin on board + glucose controlled youtube.com/shorts/z7prN... #EMIMCC

pharmacokinetics trick: let’s say a med (eg metoprolol) is used q12hr as an outpatient if you’re worried about causing instability, you *can* cut the dose in half and give it q6hr there is no law that it MUST be given q12hr smaller intervals = smoother effect & greater titratability #EMIMCC

normal mentation *doesn't* indicate adequate systemic perfusion especially in cardiogenic shock, people can mentate well despite terrible CO & systemic perfusion poor mentation is sometimes an early sign of *septic* shock, but often a very late indicator of other shock states #EMIMCC

Fresh blog: Six pearls on heparin-induced thrombocytopenia (HIT) in 2025 💎 enoxaparin causes 10x less HIT than UFH 💎 HEP score 💎 approach to intermediate 4T score? 💎 rising use of DOACs 💎 autoimmune HITT 💎 IVIG for immediate inhibition of HIT antibodies blog emcrit.org/pulmcrit/hit... #EMIMCC

Updated the IBCC DKA chapter 🍭 Biggest changes were organizational, there is now a pretty clear & streamlined 8-step guide Biggest content change was a rewrite of the definition of DKA (but - spoiler alert - the definition remains unclear & controversial)… emcrit.org/ibcc/dka/#top #EMIMCC

IV insulin is a backbone tx in hyperK Standard: 10 units IVP w/ dextrose 2021 meta(PMID: 33993515) looked at 10 units vs < 10 units No difference in reduction in serum K. Reduced risk of hypoglycemic + severe hypoglycemic events w/ reduced insulin dose youtube.com/shorts/Sz9Zy... #EMIMCC

"consensus" guideline on the management of DKA & HHS with ZERO input from: - anyone in emergency medicine - anyone in critical care - anyone in hospital medicine the guidelines (published in 2024) contain many antiquated practices and big errors... 🧵#1/3 #EMIMCC pubmed.ncbi.nlm.nih.gov/39052901/

Experience Lasting Moments, a #fundraising event with stunning #photography & limited-edition prints supporting TWCC’s #palliative care work in South Asia 📅 Oct 25: Join us in Abbotsford, BC! lnkd.in/gZB98e8T 🌐 Everywhere else? Our online Square-Print Sale Oct 15–30 twoworldscancer.ca/cart

New study supporting phenobarb monotherapy for EtOH withdrawal😍 We’ve been seeing more pts with *combined* withdrawal lately (eg opioid + EtOH) IMHO phenobarb is esp useful in complex withdrawal to tx EtOH w/d, avoid delirium, and avoid excessive GABA #EMIMCC #1/2 jamanetwork.com/journals/jam...

NLR isn't perfect, but it's a whole lot better than WBC it can be an early signal of serious trouble or, if NLR is normal, it argues against sepsis (look for some other problem) NLR-blind clinicians will think you're a genius 😆 full discussion of NLR here: emcrit.org/pulmcrit/nlr/

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

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

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

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

📊 See the figure below to review antifungal coverage.

Learnt something new today! Ketogenic diet (KD) in super refractory status epi! There's some emerging data suggesting KD may help adults w/ SRSE...based mostly on small icu studies & peds data. Case series report 70-85% SE resolution often w/in 2-5 days of ketosis #medsky #pharmsky #EMsky #neurosky

Time to Ditch Andexanet Alfa? -ANNEXA-1: No mortality benefit, incr VTE -Real world data: Rech 2025 (PMID:40700941) no improved outcomes, 9% incr VTE w/ andexanet alfa (NNH = 11) Mounting evidence that andexanet offers no benefit while increasing complications youtube.com/shorts/7DGcv... #EMIMCC

The need to deprescribe! www.nytimes.com/2025/09/07/h... (gift link) Older peeps and falls, often prescription drugs to blame.

Epinephrine in asthma -Crashing asthmatic pts may not respond to inhaled bronchodilators: severe bronchoconstriction limits med delivery -Parenteral bronchodilators ➡️ rapid bronchodilation + can be life-saving -Parenteral Epi dose: 0.5 mg IM or 50 mcg IV youtube.com/shorts/MlQu5... #EMIMCC

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

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

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

How many of us working in the ICU use the term "stress dose steroids" daily but are unsure where the term comes from? For me, I learned how to order hydrocortisone well before I understood “why” these doses were used. Read below for a quick thread on stress dose steroids! 1/8

🚨 New on REBEL EM! 💨💉 Nebulized TXA for Hemoptysis ⚡ 72% stopped bleeding in 30 min (vs 51% w IV) 📉 Fewer procedures: 25% vs 48% BAE 🌬️ Easy, cheap, non-invasive ✅ Bottom Line: Neb TXA is safe, accessible & effective—but needs more validation. 👉 https://wp.me/pdrP8b-5om #EMIMCC #FOAMed #MedSky

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