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

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

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

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

New network meta-analysis on antiemetic efficacy. Network metas are generally very fragile & kinda sus. But some data is better than no data. Evidence on antiemetic efficacy is VERY sparse (the meta doesn't even include olanzapine 😕 one of my favorite antiemetics)... 🧵 #1/5. #EMIMCC

Let’s Play Right Drug, Wrong Dose: Rocuronium Wrong: 0.6 mg/kg Right: 1.2 mg/kg Electricity in Cardioversion Wrong: start w/ 50J Right: start w/ max (200 J) Epi in Anaphylaxis Wrong: 0.3 - 0.5 mg IM Right: 0.5 mg IM - simplify decision in critical scenario youtube.com/shorts/nUTwH... #EMIMCC

when to start anticoagulation after ischemic stroke 2/2 AF? balancing risk of recurrent stroke vs. hemorrhagic transformation CATALYST: new meta-analysis of RCTs showing earlier initiation of DOAC reduces stroke w/o causing bleeds I defer this to stroke neurologists, but good to know #EMIMCC

Opiate Toxicity + Reversal - Opiate toxicity causes hypoventilation. Need to follow RR + EtCO2 - O2 sat can mislead you to thinking all fine when pt w/ severe hypovent - Key to naloxone is to give the minimal dose necessary to reverse respiratory depression youtube.com/shorts/EvpZK... #EMIMCC

rapidly pushing IV calcium may cause: 😦 vasodilation, bradycardia, hypotension 😦 nausea/vomiting, flushing if patients are conscious, this can make them feel horrible if the patient is obtunded & not intubated, emesis can be a big problem whenever possible, give IV Ca slowly #EMIMCC

I'm working on creating a critical care drug handbook (embedded into the IBCC, for free). Working version here: emcrit.org/ibcc/drugs/ Are there other drugs that you'd like to see included? (Apologies in advance for not including drugs that are exclusively available outside the USA) #EMIMCC

K3tamine is fantastic for pain management -Particularly useful in patients w/ pain refractory to opiates or on chronic opiates (Oncologic pain, sickle cell disease) -Dose 0.1 - 0.3 mg/kg -Give as infusion to avoid perceptual disturbance youtube.com/shorts/59FI9... #EMIMCC

A great post and reminder of the importance of considering drug interactions (in this case, CYP2D6 metabolism for opioids!) and genetic polymorphism #medsky #pharmsky #EMsky #GPsky #FOAMed #emimcc

analgesia & pharmacology nerds: is there a reason we don't use nalbuphine more often for analgesia? seems like a nice option, especially for patients at-risk for respiratory suppression my guess is it's a cost issue? (article: pmc.ncbi.nlm.nih.gov/articles/PMC...) #EMIMCC #Pharmsky

🌟 ABX Pearl of the Day: UTI in males ❓ Q: My male patient with dysuria is growing E. coli (>100,000 CFU/mL) on urine culture. He has no systemic symptoms or signs of pyelonephritis or prostatitis. Does he have a complicated UTI? #IDsky #medsky #meded #pharmsky #skyRX #AMSsky

My thoughts on community-acquired PNA in 2025 🫁 Disagree with POCUS as CXR replacement 🫁 Steroid now officially recommended in severe CAP 🫁 Doxy is the new azithro 🫁 DRIP score to guide beta-lactam backbone 🫁 3-7 day duration, clinical stopping criteria blog: emcrit.org/pulmcrit/202... #EMIMCC

Thanks for this Josh! 😊 absolutely, bactericidal vs bacteriostatic isn’t a thing…no difference in mortality & cure outcomes except for when in immunocompromised pts (bc these pts were excluded from studies) #medsky #EMsky #pharmsky #IDsky #emimcc #FOAMed

our lab recently got the ability to check quantitative apixaban levels results are often shocking sometimes: patient “on apixaban” has zero level sometimes: patient who has been off apixaban for days still has a huge level (renal, hepatic dysfunx, elderly) (more: emcrit.org/ibcc/heparin...)

One of my favorite training videos for my residents! “This is exemplary CPR” 🤣 quality CPR saves lives! #medsky #EMsky #nursesky #cpr #acls #pharmsky #emimcc x.com/EM_RESUS/sta...

PT virtually useless in assessing coagulation status in cirrhosis -Cirrhosis ➡️ abnormal synthetic fxn clotting factors + anticoags -Unlike w/ warfarin, lowering of factors isn’t uniform -Can have massive depletions in one factor + normal levels of others youtube.com/shorts/W51lW... #EMIMCC

Thanks for this post Anand!! 😊 Adding that atropine is often ineffective in BRASH. Epinephrine and isoproterenol usually needed for HR and perfusion support in severe cases #medsky #EMsky #emimcc #pharmsky

#EMIMCC #FOAMed #MedSky

an article about BlueSky that isn’t dumb 😆 this rings true to me a social media app doesn’t need 300 million people to be great nobody interacts with millions of people really you just need a couple hundred great people to interact with https://cybernews.com/tech/bluesky-catch-up-x-threads/

🌟 ABX Pearl of the Day: penicillin allergies ❓ Q: My patient reports a reaction to penicillin (acute, self-limited rash) over 10 years ago. Can they safely receive cefazolin for their MSSA infection? #IDsky #medsky #meded #pharmsky #skyRX #AMSsky

Case series w/ cumulative total n=110 pts support use of rivastigmine as alternative antidote to physostigmine for anticholinergic delirium. Both oral & transdermal formulations of rivastigmine may expedite recovery #medsky #EMsky #pharmsky #emimcc #FOAMed Full-text available 👉: rdcu.be/ewgoc

Case series w/ cumulative total n=110 pts support use of rivastigmine as alternative antidote to physostigmine for anticholinergic delirium. Both oral & transdermal formulations of rivastigmine may expedite recovery #medsky #EMsky #pharmsky #emimcc #FOAMed 👉 link.springer.com/article/10.1...

Now hearing rumours of a spironolactone shortage 😱 Anyone else hearing this? #MedSky #PharmSky

Advice for New Trainees #1: Say “I Don’t Know + Why.” Communicate humility + intellectual curiosity; two of the most important characteristics in building a successful career in medicine The most frequent word out of a trainees mouth should be “why” youtube.com/shorts/VH1Ki... #EMIMCC

Advice for New Trainees #2: Listen to your nurses Don’t mistake your short time as a doctor as equivalent clinically to their years and decades of experience If a nurse asks you to reevaluate a patient, GO TO THE BEDSIDE AND RE-EVALUTE THE PATIENT, EVERY TIME. youtube.com/shorts/c0o5F... #EMIMCC

Occult VF in Cardiac Arrest: 5.3% of patients with cardiac arrest showed VF on echo but ECG w/ PEA/asystole Study does not show improved outcomes but not powered to do so Strong argument for intra-arrest echo as it can dramatically change management #EMIMCC

Thnx for this great post! Makes me wonder how many patients we’ve put on ertapenem for ESBL infxns in our medical infusion clinics without considering their albumin status/level…something I’ll keep in mind moving fwd! 🤔 #medsky #EMsky #pharmsky #FOAMed #IDsky #AMSsky #emimcc

Great article on dogma in ID (with parallels to critical care) We have HUGE problems re: guidelines making recommendations & *redefining* entire diseases based on minimal data. Gov't metrics exacerbate this further. @bradspellberg.bsky.social @absteward.bsky.social @drtoddlee.bsky.social #EMIMCC

Hypokalemia big killer in DKA -All DKA patients total body K down -Some w/ serum hyperK due to acidosis shifting K -K < 3.5: replete prior insulin -K 3.5-5.5: start insulin + K repletion simultaneously -Skip bolus: no faster DKA resolution but incr risk hypoK youtube.com/shorts/pTnt8... #EMIMCC

short 🧵 on antifibrinolytics for bradykinin-mediated angioedema 😃 bradykinin-mediated angioedema involves a metabolic spiral shown below👇 tPA is part of this spiral, which explains why 🩸 tPA can *cause* angioedema 🩸antifibrinolytics can *treat* angioedema (IBCC emcrit.org/ibcc/angioed...) #EMIMCC

standard approaches to dosing hypertonic therapy are flawed 🧂for hyponatremia, reviews often recommend homeopathically low doses (eg 100cc of 3%) 🧂for elevated intracranial pressure, common practice is to use fixed doses (eg 30 cc 23.4% saline for everyone) can we do better?... 🧵 #1/2 #EMIMCC