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

In ICH, should we be cautious w/ hydralazine for BP control? Commonly used w/ labetalol...hydralazine is a direct cerebral vasodilator that can ↑cerebral blood volume and ICP, potentially ↓CPP in patients with impaired autoregulation or mass effect Thoughts? #EMsky #EMIMCC #neurosky #pharmsky

In ICH, should we be cautious w/ hydralazine for BP control? Commonly used w/ labetalol...hydralazine is a direct cerebral vasodilator that can ↑cerebral blood volume and ICP, potentially ↓CPP in patients with impaired autoregulation or mass effect Thoughts? #EMsky #EMIMCC #neurosky #pharmsky

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

*Pulmonary embolism* versus *Acute myocardial infarction*: Above and below the pen: the size of the clots in each scenario I was looking for a picture like this and found it in a lecture by Dr Sripal Bangalore #foamed #foamcc #meded #Medsky #emimcc

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

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

😨 for all my medical and #pharmacy friends (and/or #Pokemon fans!), try this challenge!!! Is it a Pokemon or drug name?? 🤔 #medsky #pharmsky #RxSky #nursesky I failed miserably lol 🤦🏻‍♂️ (I’m not familiar with my brand names for medications…)

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

🔥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

Here’s a short skeetorial to raise awareness about the surprisingly high sodium content in some IV antibiotics...clinically important for patients with CHF. Judicious use matters!💧🧂 #emimcc #medsky #EMsky #IDsky #pharmsky #AMSky #FOAMed

Here’s a "shorter" (😅) tweetorial…why do we use a combination of beta-lactam + vancomycin for cellulitis or MSSA bacteremia? If vancomycin covers both strep and staph, why not use it alone? Let’s dive in! 🧵 #medsky #pharmsky #EMsky #MedEd #IDsky #AMSky #nursesky

Thought I'd repost a relevant skeetorial from last year! I often get asked about renal dosing adjustments of Abx in critically ill pts in the ED, so I'd thought I'd share my thought process & perspective. Caveat: only in ED! Lets dive in! 👇 #medsky #pharmsky #EMsky #IDsky #emimcc #MedEd

In critically ill pts, avoid adjusting initial doses based solely on early bloodwork. When pts present to ED, SCr/eGFR may not accurately reflect kidney fxn. These early labs represent pre-treatment📷(before IV💧, Abxs & resus). W/ these interventions, SCr/eGFR often improves #emimcc #medsky #pharmsky

Love to hear others’ experience... How has IV push antibiotics been working in ur ED? Any challenges w/ nurses having to push over 2–5 min vs hanging infusion & multitasking? Has IV Abx use ↑ from AMS pov? Would love to learn from others’ workflows & outcomes☺️ #nursesky #medsky #EMsky #AMSSky #IDsky

Be cautions intubating patients w/ severe metabolic acidosis -Hyperperpnea drives CO2 down supporting pH -Removing resp drive will drop pH ➡️ HD collapse -Mech vent challenging as must mimic preintubation parameters -Use NIV to support work of breathing instead youtube.com/shorts/zn7hi... #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

It took us a while to recognize euglycemic diabetic ketoacidosis (euDKA) in patients treated with Na-glucose cotransporter-2 inhibitors. It seems that we may have to be on the lookout for euDKA in patients treated with glucagon-like peptide-1 receptor agonists (#Ozempic #Zepbound)

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

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

#NephJCshort on BICAR-ICU2 #Medsky #Nephsky ✍️ By @nephroseeker.medsky.social 🎭 Bicarbonate makes the picture look cleaner: better pH, more time. But beneath the smoother numbers, the patient hasn't changed. It's the same story, just told in softer colors www.nephjc.com/news/2025/10...

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

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