what is your best pearl, or most useful reference, about interpreting a complete blood count with differential? The blood count is one of the most commonly ordered tests in clinical medicine, but its subtleties are woefully overlooked. #EMIMCC

ED Cardioversion of recent onset AF safe + effective in selected groups: -On AC > 3 weeks regardless of onset -Low risk by structured tool (CHADS-VASC) < 48 hours from onset -High-risk + presents < 12 hours from onset Low risk CHADS-VASC < 2 (men) < 3 (women) youtube.com/shorts/Xdpbk... #EMIMCC

We worry a lot about “too much Keppra” but in status epilepticus the greater risk may be underdosing the initial load. Neuropsychiatric adverse effects are largely linked to ongoing maintenance therapy, not a single appropriately dosed loading dose #emimcc #FOAMed #EMsky #RxSky

Agree with this All formulae for corrected calcium are imperfect Just measure ionized calcium pubmed.ncbi.nlm.nih.gov/42035248/ #EMIMCC

This dogma must stop being taught to clinicians and be put out to pasture as a relic of a bygone era in scientific literature. I love this 😍 What other dogmas should we retire? #idsky #microsky #EMIMCC

everyone learns about TCA overdose in med school, but not bupropion XR overdose time to level up bupropion XR overdose is increasingly common & VERY dangerous ongoing drug absorption creates a "toxin bomb" wherein patients look OK initially, but deteriorate later on... (#1/2) #EMIMCC

Propofol in RSI -Unlike ketamine + etomidate, propofol has intrinsic HD effects (vasodilation + cardiac depression) -If using in patients w/ even slight HD compromise, be careful w/ dosing -Can use reduced bolus dose or titrate in small aliquots youtube.com/shorts/p3aji... #EMIMCC

Cool study - an amp of sodium bicarbonate (50 ml 8.4%) raises sodium similar to a boils of 3% - as expected of course! pubmed.ncbi.nlm.nih.gov/41937305/ @pulmcrit.bsky.social @kidneyboy.bsky.social #nephsky #emimcc

medicine of the PITT: status epilepticus in pregnancy if you're using levetiracetam as your go-to antiseizure med (as most folks are), then the treatment is essentially the same as usual add Mg, but Mg prevents sz recurrence (rather than lysing active sz) #1/2 #EMIMCC

Myth: Ketamine increases ICP in TBI ➡️worse outcomes -Myth originates from low quality data -Recent data shows ICP unchanged + CPP unchanged or slight incr -Ketamine advantages: more HD stable + physiologically may be beneficial -Bottom line: safe to use in TBI youtube.com/shorts/deykT... #EMIMCC

is there a reason that we don't use more IV glycopyrrolate for status asthmaticus? admittedly minimal direct evidentiary support, but makes sense & indirect evidence seems more benign than various alternative treatments (eg intubation, ECMO, extracorporeal CO2 removal). #EMIMCC

Orthostatics worthless in assessing volume status -50% > 65 + 44% teens orthostatic at baseline(PMID 9109468, 12006955) -Perform poorly in known volume loss(PMID 8198307) -Useless in assessing those w/ fluid depletion from vomiting, diarrhea (PMID 10086438) youtube.com/shorts/Dvq5R... #EMIMCC

Surviving Sepsis 2026 is here & it's even more loony tunes than I was expecting. They're promoting pre-hospital ABX & preemptive broad-spectrum IV antibiotics for intubated patients. This insane fever dream is an antimicrobial stewardship nightmare. Embarrassment for SCCM. #EMIMCC

kudos to ACEP for calling out the Surviving Sepsis Campaign 2026 guidelines and not joining in this madness. ACEP is great at making evidence-based policies that actually *help* provide better patient care. When ACEP is politely burning your guideline, you’re in trouble. #EMIMCC

One point that isn't mentioned here but too often forgotten when noradrenaline seemingly isn't working: Are you actually using a representative blood pressure? Not so rare that a better (more central or better line) fixes the problem. Look at the whole patient, not just a number! #emimcc #cccsky

Sux Contraindications -Bumps K by ~ 0.5 mEq: Problem if ESRD/CKD + unknown K -Exaggerated incr K in malignant hyperthermia, motor neuron disease, muscular dystrophy, GBS -While these situations are uncommon, adds to cognitive load in high stress scenario youtube.com/shorts/kD2IK... #EMIMCC

Safe to give 3% hypertonic saline through a peripheral IV bit.ly/49t5GcI Retrospective study w/ 216 administrations of 3% by PIV + only 8 minor complications Bottom line: don’t delay 3% hypertonic administration for placement of a central line youtube.com/shorts/M5AyB... #EMIMCC

The end of the road for rivaroxaban? Shows how important direct comparative trials among drugs within the same pharmacologic class are. #emimcc #cardiosky www.nejm.org/doi/full/10....

Here's a DOAC–CYP interaction workaround. If DOAC is needed w/ CYP3A4 concerns, consider edoxaban. It’s <4% metabolized by CYP3A4 unlike apixaban, rivaroxaban & dabigatran (20-50%). Caveat..avoid if CrCl>95 mL/min...renal clearance is too efficient, reducing efficacy👇 #emimcc #medsky #hemesky #Rxsky

Steroids in Asthma Exacerbations -Short course of steroids reduce ED revisits/admissions -Anti-inflammatory reduce bronchial inflammation + bronchospasm -Also upregulate beta receptors in lung incr sensitivity to inhaled beta agonists (effect kicks in in minutes) youtube.com/shorts/PopLV... #EMIMCC

Finally the Hyponatremia Intervention Trial is published and it is a big disappointment pbfluids.com/2026/03/fina...

New JAMA review attempts to equate pulmonary congestion with systemic congestion ("volume overload") This is sloppy & often wrong Pts w/ LV failure often have pulmonary congestion w/o systemic congestion Pts w/ RV failure usually have systemic congestion w/ dry lungs CVP isn't PCWP #EMIMCC

For #PharmacyAwarenessMonth, I’m highlighting the role of EM pharmacists in cardiac arrest, traumas & intubations…one of many ways #pharmacists make a difference each day! Optimize #meds, ↓errors, improve lifesaving care timing. Proud to stand with dedicated pharmacists☺️💪🔥 #pharmacy #Rxsky #EMsky

Happy Pharm Awareness Month #PAM2026 to my incredible pharmacy colleagues in Canada & around the🌏! Proud to be a pharmacist alongside such dedicated colleagues. The work we do isn’t always easy but it matters...every💉💊, every💬, every🤒we help. Grateful to be in this with all of you 🙏 #pharmsky #RxSky

🔥Just published 🔥 TAPER-V RCT In this RCT of 256, a 4-week vancomycin pulse and taper regimen *had a probability of 74% to be superior to a standard 2-week pulse regimen in patients a first episode or first recurrence of CDI Vanco for 10d is obsolete! #IDSky #EMIMCC jamanetwork.com/journals/jam...

Insulin bolus typically not necessary in DKA but, consider if: Delay in getting insulin drip from pharamacy. Severe acidosis: reach therapeutic levels faster + fix the acidosis faster Bolus dose: 0.1 U/kg youtube.com/shorts/pYybS... #EMIMCC

Fresh Blog: Mythbusting the use of beta-blockers for sinus tachycardia in thyroid storm This is one of the most dangerous & pervasive myths currently in circulation about acute care B-bl commonly precipitate shock or even arrest in these patients...(#1/2) blog: emcrit.org/pulmcrit/tst... #EMIMCC

There are few absolute rules in medicine but «never treat sinus tachycardia, treat the cause» has extremely few exceptions. #emimcc #cardiosky #medsky

1/🧵what happens after stopping #glp1 agonists like #semaglutide (#Wegovy #Ozempic) or tirzepatide (#Mounjaro #Zepbound)? Recent BMJ analysis looked at #weight regain & cardiometabolic changes after discontinuation. Let’s break it down 👇 #medsky #pharmsky #IMsky #Endosky #diet #lifestyle

Avoid crystalloid in hemorrhagic shock -May incr BP but not O2 carrying -Dilute Hgb + clotting factors -Saline contributes to acidosis + cold fluids contribute to hypothermia which worsens clotting Patients don’t bleed crystalloid so don’t give crystalloid youtube.com/shorts/QltA6... #EMIMCC

The new 2026 AHA/ASA stroke guidelines include this table 👇 for the management of thrombolytic-induced angioedema. There is NO discussion or any additional text about this topic. I find this to be insufficient, not evidence-based, and potentially confusing... #1/2 #EMIMCC

Bicarb Pushes -Na channel blockade on heart: TCA + diphenhydramine toxicity (narrows QRS + stabilizes patient) -Salicylism: alkalinizes urine incr toxin excretion -HypoNa w/ seizures or significant neurological dysfunction when hypertonic saline not available youtube.com/shorts/gQrwA... #EMIMCC

1/🧵what happens after stopping #glp1 agonists like #semaglutide (#Wegovy #Ozempic) or tirzepatide (#Mounjaro #Zepbound)? Recent BMJ analysis looked at #weight regain & cardiometabolic changes after discontinuation. Let’s break it down 👇 #medsky #pharmsky #IMsky #Endosky #diet #lifestyle

Had a great time running workshop on cardiogenic shock/critical care cardiology for early career cardiology trainees yesterday. A repeat question was wether I have a blood pressure limit for when I give diuretics. I don’t. If the patient is truly volume overloaded, the bp won’t ⬇️ from the diuretic

No role for bicarb pushes in metabolic acidosis -Bicarb only incr pH if incr ventilation -Met acidosis w/ resp alkalosis are maximally ventilating + blowing off CO2 -Intubating unlikely to help -Bicarb pushes will worsen acidosis if not increasing ventilation youtube.com/shorts/uS2VN... #EMIMCC

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