Have successfully managed many of these pts. NIPPV is really 1a and NTG 1b. Have never really understood really high doses of NTG; have seen resultant hypotension and other extraneous cognitive load. Also data not robust for improving meaningful outcomes. #emimcc
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.
Incredible work. Thx for regularly elevating core clinical practice.
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
Agree with a lot of this. Thx for your high-level work and time.
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
