Really excited to publish in @emdocs about FOAM Cortex (foamcortex.com). FOAMed resources like emDocs are amazing—our goal is to help get that knowledge to the bedside faster. #FOAMed hashtag#MedEd. www.emdocs.net/foam-cortex-... @emhighak.bsky.social

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

Don’t reflexively start B-blockers without looking at old data points and collecting new ones as subset of these pts have mod/severe decr in EF and will decomp. Esmolol over propranolol as you can stop drip. #emimcc

Nuanced understanding of spectrum of any disease is so important. Not a one-size fits-all approach. Reflect on your current practice. Aggressively learn from cases with any angst/conflict. This is how you elevate care and your field. #emimcc

#4/4) ascenting cholangitis generally IS infected & OFTEN causes septic shock be wary of patients w/ ascending cholangitis who seem OK (may crash) source control is usually obtained via ERCP. this should be done regardless of how sick the patient is (nobody is “too sick” for source control).

#3/4) percutaneous drainage is over-utilized for acute calculous cholecystitis (2/2 pressure to do something now) no high-quality data supporting drain insertion (RCTs failed to find benefit) the ideal therapy for most patients is medical stabilization followed by early laproscopic cholecystectomy

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

Crucial to learn from all fields of medicine in order to provide thoughtful, comprehensive care for the pts in front of us #emimcc

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...

1 more point that will sharpen your clinical gestalt and decision making. Details matter, particularly in EM. #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

Spectrum of disease w nuanced management. Hard to flesh out.

Quite thoughtful on your end @pulmcrit.bsky.social. Something that would definitely benefit from standardization and benefit critically ill pts.

Answer: #2 normotensive cardiogenic shock It’s sneaky, easy to miss but important to identify, diagnose cause, manage and admit to ICU—not the floor tele unit Occurs in about 12% of CS patients Mortality 17% www.jacc.org/doi/10.1016/...

if you see a gram-negative that is resistant to ceftriaxone, this is a red flag for possible ESBL. even if lab report states that the bacteria is "sensitive" to ceftazidime, cefepime, or piptazo, it may be advisable to avoid these.

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

The cognitive pause in refractory hypotension reminds us to stop, question our diagnosis + assumptions and consider alternate/additional pathologies - Acidosis - Hypothyroidism - Iatrogenic anaphylaxis - Hypocalcemia - Occult hemorrhage - RUSH Exam youtube.com/shorts/bvWoL... #EMIMCC

to recap: the dosing of antiepileptics for true, ongoing, life-threatening convulsive status epilepticus in an adult: 1st line: 👊Lorazepam 0.1 mg/kg IV (VA-COOP RCT) 👊Or if no IV access: Midazolam 10 mg IM (RAMPART RCT) 2nd line: 👊Levetiracetam 60 mg/kg up to a max dose of 4.5 grams (ESSETT RCT)

Released today. Pls check out what makes EM unique and at the core of medicine: www.amazon.com/Emergency-Me.... Deep thx to remarkable authors/leaders in our field. #foamed #medsky #emimcc

I have been doing this for 10 years now - some reflections on #FOAMed and the future of First10EM

PulmCrit blog: Michelin Chest Syndrome A shallow pigtail chest tube straightens out & lacerates the lung… Side-holes in the chest wall function as a conduit, pushing air into the subcutaneous tissue… Massive subcutaneous emphysema occurs blog: https://emcrit.org/pulmcrit/michelin-chest-syndrome/

Please check this out: www.amazon.com/Emergency-Me.... Our field is so complex and crucial to success of medicine. #emimcc #medsky

Check out latest in EM decision making series: www.sciencedirect.com/science/arti.... Thx BLong, JEaster. #medsky #emimcc

Very interested to hear what folks think of this for EM: www.acgme.org/globalassets... #medsky #emimcc

version for new AF in ICU pt who needs urgent (not emergent) cardioversion: 1) start protocoled Mg gtt 1 g/hr 2) amio load & gtt 3) wait a few hrs 4) 1 mg ibutilide 5) if still in AF: DCCV meds build up & work together Mg/ibutilide/amio are synergistic Mg prevents ibutilide-induced TdP #EMIMCC

Fave afib management pearls? #medsky #emimcc @pulmcrit.bsky.social @emcases.bsky.social @petrosoniak.bsky.social @first10em.bsky.social @skylerlentz.bsky.social

Fave risk stratification tools / pearls re: using them? #medsky #emimcc @pulmcrit.bsky.social @emcases.bsky.social @petrosoniak.bsky.social @first10em.bsky.social @skylerlentz.bsky.social

common error: we decide to perform procedures based on the *absolute* risk, not the risk/benefit *ratio* for example: 1) unnecessary procedure is done on a healthy patient 2) necessary procedure isn't done on a high-risk patient #EMIMCC

milrinone pharmacology drives me crazy half-life is ~2 hrs (longer in renal dysfunction, which our patients often have) without a bolus, levels won't hit steady state for >4 hr how does it make mathematical sense to give this drug without a bolus in an acutely sick patient? 🧵#1/2

Please check this out: www.amazon.com/Emergency-Me.... Unique thought process and central role in medicine. #medsky #emimcc

“Our shared humanity is more important than any political disagreement or cultural divide.” -Bill Clinton, Citizen #medsky #emimcc

Some of my fave clinical pts. #emimcc #medsky

Success is rarely linear; it’s often the sum of detours, setbacks, and unexpected turns. -BMezrich

A star wants to see themselves rise to the top. A leader wants to see those around them rise to the top. -SSinek

Working hard for something we don’t care about is called stress; working hard for something we love is called passion. -SSinek

Speak when you are angry and you will make the best speech you will ever regret. -Ambrose Bierce

Top mixture of 2024 emdocs.net posts: www.emdocs.net/top-emdocs-p... #emimcc #medsky

disagree with this “triangle of saftey” nonsense in morbid obesity or cardiomegaly, this location could be dangerous (eg, diaphragm can be really high) so POCUS is key to establish anatomy before tube insertion (and incidentally, ICU patients never look like this in real life 🙄) #EMIMCC

GBS challenging identification: www.emdocs.net/emdocs-podca... #medsky #emimcc

Vtach med options: www.emdocs.net/does-the-lit... #medsky #emimcc

Check out an update on alcohol withdrawal: www.emdocs.net/emdocs-revam... #emimcc #medsky

Focused ultrasound should replace many aspects of our current physical exam. #emimcc #medsky

Mastery of clinical care is the purest form of patient and social advocacy in our field. #emimcc #medsky

Beware negative inotropy for rate control in patient with subtle cardiogenic shock. #medsky #emimcc

Iron tox pearls/pitfalls: www.emdocs.net/toxcard-iron/ #medsky #emimcc #foamed

the key clue here is the neutrophil/lymphocyte ratio is 101! that's super high and *way* above what would be expected in DKA without an underlying infection (usually below ~15ish) for context, NLR >15 is in a range consistent with septic shock 🧵 4/5 pubmed.ncbi.nlm.nih.gov/35071771/

Latest on mpox: www.emdocs.net/mpox-in-adul... #emimcc #medsky #foamed

Check out the latest posts: www.emdocs.net. Fantastic variety of our much-needed field. #medsky #emimcc

New assistive walking device, think new pathology exists. #emimcc #medsky