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
(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
Stop using steroids to pretreat CT contrast allergy
youtube.com/watch?v=h2Hv...
youtube.com/watch?v=h2Hv...
Steroids are OUT for CT contrast allergy
YouTube video by First10EM
youtube.com
November 18, 2025 at 1:51 PM
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
(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
Finished updating the IBCC chapter on septic shock
This algorithm is where I ended up 👇
Therapies should be based on several factors (not solely whether CRT is <3; CRT isn't precise so this dichotomy is problematic)
Beware of vasopressin; it may depress digital perfusion & block the goal #EMIMCC
This algorithm is where I ended up 👇
Therapies should be based on several factors (not solely whether CRT is <3; CRT isn't precise so this dichotomy is problematic)
Beware of vasopressin; it may depress digital perfusion & block the goal #EMIMCC
November 19, 2025 at 2:01 PM
Finished updating the IBCC chapter on septic shock
This algorithm is where I ended up 👇
Therapies should be based on several factors (not solely whether CRT is <3; CRT isn't precise so this dichotomy is problematic)
Beware of vasopressin; it may depress digital perfusion & block the goal #EMIMCC
This algorithm is where I ended up 👇
Therapies should be based on several factors (not solely whether CRT is <3; CRT isn't precise so this dichotomy is problematic)
Beware of vasopressin; it may depress digital perfusion & block the goal #EMIMCC
Priorities in UGIB management: blood, ceftriaxone (if varices suspected), GI to bedside + consider intubation
Finer point: administration of metaclopramide + erythromycin
Promotility agents which help empty the stomach of blood, improve the view for endoscopist
youtube.com/shorts/ae98W...
#EMIMCC
Finer point: administration of metaclopramide + erythromycin
Promotility agents which help empty the stomach of blood, improve the view for endoscopist
youtube.com/shorts/ae98W...
#EMIMCC
Promotility Agents in UGIB #criticalcare #emergencymedicine #resuscitation
YouTube video by EMSwami
youtube.com
November 19, 2025 at 3:20 PM
Priorities in UGIB management: blood, ceftriaxone (if varices suspected), GI to bedside + consider intubation
Finer point: administration of metaclopramide + erythromycin
Promotility agents which help empty the stomach of blood, improve the view for endoscopist
youtube.com/shorts/ae98W...
#EMIMCC
Finer point: administration of metaclopramide + erythromycin
Promotility agents which help empty the stomach of blood, improve the view for endoscopist
youtube.com/shorts/ae98W...
#EMIMCC
Single-center RCT finds benefit from sepsis resus that targets perfusion index (Pi)
Intervention group: fix macrohemodynamics, then target Pi >1.4
I think they're right
Pi is similar to cap refill, but continuously displayed number on monitor 😍
pubmed.ncbi.nlm.nih.gov/41033063/ #EMIMCC
Intervention group: fix macrohemodynamics, then target Pi >1.4
I think they're right
Pi is similar to cap refill, but continuously displayed number on monitor 😍
pubmed.ncbi.nlm.nih.gov/41033063/ #EMIMCC
November 18, 2025 at 3:15 PM
Single-center RCT finds benefit from sepsis resus that targets perfusion index (Pi)
Intervention group: fix macrohemodynamics, then target Pi >1.4
I think they're right
Pi is similar to cap refill, but continuously displayed number on monitor 😍
pubmed.ncbi.nlm.nih.gov/41033063/ #EMIMCC
Intervention group: fix macrohemodynamics, then target Pi >1.4
I think they're right
Pi is similar to cap refill, but continuously displayed number on monitor 😍
pubmed.ncbi.nlm.nih.gov/41033063/ #EMIMCC
Fluids in HyperK
-Restore volume, incr kidney perfusion leading to incr urine output + K elimination
-0.9% saline: pH 5.5, big Cl load. Worsen acidosis leading incr serum K
-LR superior: small amount of K in it won’t raise serum K. Won’t contribute to acidosis
youtube.com/shorts/3G4yc...
#EMIMCC
-Restore volume, incr kidney perfusion leading to incr urine output + K elimination
-0.9% saline: pH 5.5, big Cl load. Worsen acidosis leading incr serum K
-LR superior: small amount of K in it won’t raise serum K. Won’t contribute to acidosis
youtube.com/shorts/3G4yc...
#EMIMCC
Fluids in Hyperkalemia #criticalcare #emergencymedicine
YouTube video by EMSwami
youtube.com
November 21, 2025 at 2:31 PM
Fluids in HyperK
-Restore volume, incr kidney perfusion leading to incr urine output + K elimination
-0.9% saline: pH 5.5, big Cl load. Worsen acidosis leading incr serum K
-LR superior: small amount of K in it won’t raise serum K. Won’t contribute to acidosis
youtube.com/shorts/3G4yc...
#EMIMCC
-Restore volume, incr kidney perfusion leading to incr urine output + K elimination
-0.9% saline: pH 5.5, big Cl load. Worsen acidosis leading incr serum K
-LR superior: small amount of K in it won’t raise serum K. Won’t contribute to acidosis
youtube.com/shorts/3G4yc...
#EMIMCC
Reharing my #shiny leaf plot app, demonstrating the relationship between prevalence/pre-test probability, sensitivity, specificity and post-test probabilities. lmsaxhaug.shinyapps.io/Leaf_App/ #rstats #meded #emimcc #cardiosky #medsky
November 17, 2025 at 9:50 AM
Reharing my #shiny leaf plot app, demonstrating the relationship between prevalence/pre-test probability, sensitivity, specificity and post-test probabilities. lmsaxhaug.shinyapps.io/Leaf_App/ #rstats #meded #emimcc #cardiosky #medsky
Whenever someone talks about vascular leakage being a primary pathology in septic shock (like in anaphylaxis), I point out that patient's with sepsis don't present with hemoconcentration and oedema (unlike anaphylaxis), the oedema does not come before we give them fluids. #emimcc
November 15, 2025 at 11:12 PM
Whenever someone talks about vascular leakage being a primary pathology in septic shock (like in anaphylaxis), I point out that patient's with sepsis don't present with hemoconcentration and oedema (unlike anaphylaxis), the oedema does not come before we give them fluids. #emimcc
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
(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
November 13, 2025 at 6:52 PM
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
(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
Fresh IBCC: POCIT (Point-of-care infrared thermography)
This is basically where POCUS was 1995-2005
Technology & evidence-basis are improving
Early adopters may be interested
IMHO anything bringing us to the bedside more & forcing us to engage w/ the exam is good
emcrit.org/ibcc/pocit/ #EMIMCC
This is basically where POCUS was 1995-2005
Technology & evidence-basis are improving
Early adopters may be interested
IMHO anything bringing us to the bedside more & forcing us to engage w/ the exam is good
emcrit.org/ibcc/pocit/ #EMIMCC
November 13, 2025 at 2:00 PM
Fresh IBCC: POCIT (Point-of-care infrared thermography)
This is basically where POCUS was 1995-2005
Technology & evidence-basis are improving
Early adopters may be interested
IMHO anything bringing us to the bedside more & forcing us to engage w/ the exam is good
emcrit.org/ibcc/pocit/ #EMIMCC
This is basically where POCUS was 1995-2005
Technology & evidence-basis are improving
Early adopters may be interested
IMHO anything bringing us to the bedside more & forcing us to engage w/ the exam is good
emcrit.org/ibcc/pocit/ #EMIMCC
DKA with ?cerebral oedema, self ventilating her own pCO2 down to 2 (15 in 🦅 units). If she gets tubed, do I try to keep the CO2 the same, or do I aim for neuroprotective CO2?
#emimcc
#emimcc
November 13, 2025 at 2:33 PM
DKA with ?cerebral oedema, self ventilating her own pCO2 down to 2 (15 in 🦅 units). If she gets tubed, do I try to keep the CO2 the same, or do I aim for neuroprotective CO2?
#emimcc
#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
a woman says " no need for that " while wearing a jacket
ALT: a woman says " no need for that " while wearing a jacket
media.tenor.com
November 15, 2025 at 6:27 AM
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
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
-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
Nothing Normal About "Normal" Saline #criticalcare #emergencymedicine #resuscitation
YouTube video by EMSwami
youtube.com
November 12, 2025 at 2:33 PM
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
-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
your daily reminder:
☕️ coffee is great
☕️ caffeine-free diets for hospitalized patients are silly & cause misery due to caffeine withdrawal #EMIMCC
☕️ coffee is great
☕️ caffeine-free diets for hospitalized patients are silly & cause misery due to caffeine withdrawal #EMIMCC
From @jama.com: Patients with #AFib who continued their usual caffeinated coffee intake after cardioversion experienced less recurrence of AF or atrial flutter compared to those who abstained from coffee and caffeine.
#AHA25 @ahascience.bsky.social
ja.ma/3XolIkd
#AHA25 @ahascience.bsky.social
ja.ma/3XolIkd
November 9, 2025 at 3:15 PM
your daily reminder:
☕️ coffee is great
☕️ caffeine-free diets for hospitalized patients are silly & cause misery due to caffeine withdrawal #EMIMCC
☕️ coffee is great
☕️ caffeine-free diets for hospitalized patients are silly & cause misery due to caffeine withdrawal #EMIMCC
IMHO the best strategy for occasional intubators (e.g., pulm/crit) is:
-Preox with BiPAP (PREOXY trial)
-Paralyze with roc/ketamine
-Intubate with hyperangulated VL + rigid stylet
This has a very sharp learning curve
Fellows can do this ~50 times and provide reproducibly safe intubations #EMIMCC
-Preox with BiPAP (PREOXY trial)
-Paralyze with roc/ketamine
-Intubate with hyperangulated VL + rigid stylet
This has a very sharp learning curve
Fellows can do this ~50 times and provide reproducibly safe intubations #EMIMCC
Hyperangulated videolaryngoscopy: stylet first until benefit of bougie is shown
"...the current challenge for the wider community of anaesthetists ... is not mastery of HAVL but access to devices, routine use, gaining familiarly and developing competence."
#AnSky
ttps://doi.org/10.1111/anae.70062
"...the current challenge for the wider community of anaesthetists ... is not mastery of HAVL but access to devices, routine use, gaining familiarly and developing competence."
#AnSky
ttps://doi.org/10.1111/anae.70062
November 10, 2025 at 1:27 PM
IMHO the best strategy for occasional intubators (e.g., pulm/crit) is:
-Preox with BiPAP (PREOXY trial)
-Paralyze with roc/ketamine
-Intubate with hyperangulated VL + rigid stylet
This has a very sharp learning curve
Fellows can do this ~50 times and provide reproducibly safe intubations #EMIMCC
-Preox with BiPAP (PREOXY trial)
-Paralyze with roc/ketamine
-Intubate with hyperangulated VL + rigid stylet
This has a very sharp learning curve
Fellows can do this ~50 times and provide reproducibly safe intubations #EMIMCC
We dive into the subtle art of placing, understanding, and interpreting the PA (Swan Ganz) catheter, on a new lesson at icu101.com.
#emimcc #medsky
#emimcc #medsky
November 10, 2025 at 8:12 PM
We dive into the subtle art of placing, understanding, and interpreting the PA (Swan Ganz) catheter, on a new lesson at icu101.com.
#emimcc #medsky
#emimcc #medsky
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...
What are the pharmacodynamics of loop diuretics?
A recent editorial was entitled ‘Loop diuretics in heart failure: few facts and lots of prejudice’.1 I would argue that we have forgotten or distorted some
academic.oup.com
November 9, 2025 at 6:40 PM
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...
Reupping this question as I’m seeing the same, often because it is assumed to be better tolerated hemodynamically (myth?). #cardiosky #emimcc #kidneysky
Bolus or infusion of iv furosemide?
I’ve always felt that twice a day bolus is more effective but am seeing increasing use of infusions in patients under cardiology and acute medicine.
I’ve always felt that twice a day bolus is more effective but am seeing increasing use of infusions in patients under cardiology and acute medicine.
November 8, 2025 at 4:53 PM
Reupping this question as I’m seeing the same, often because it is assumed to be better tolerated hemodynamically (myth?). #cardiosky #emimcc #kidneysky
November 7, 2025 at 7:23 AM
I’m usually not one to throw shade at choosing mortality for an #ICU primary outcome… but for arterial lines? Did people think they saved lives? And this is in NEJM?
#EMIMCC #criticalcare #MedSky
#EMIMCC #criticalcare #MedSky
November 4, 2025 at 6:09 PM
I’m usually not one to throw shade at choosing mortality for an #ICU primary outcome… but for arterial lines? Did people think they saved lives? And this is in NEJM?
#EMIMCC #criticalcare #MedSky
#EMIMCC #criticalcare #MedSky
