Tessera

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

Inception: We Need To Go Deeper Meme with Leonardo DiCaprio

ALT: Inception: We Need To Go Deeper Meme with Leonardo DiCaprio

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we’ve integrated the PREOXI trial into our practice so well that there’s an entire cabinet in our ICU dedicated to it 😁 this improves intubation success & safety. I’vd wanted to do this for a decade but the RCT provided EBM backing to push it forward more here emcrit.org/pulmcrit/bsi/

Proposal: for complex patients (eg ICU) we should *always* get CBC w/ differential (not a plain CBC) - Same amount of blood - Run by the same machine (it usually CHECKS the differential & just dumps the data!) - Trivial cost difference - Can be helpful (eg Eos 2/2 drug, NLR) #EMIMCC

Beelzebub's Interesting Proposal (Good Omens)

ALT: Beelzebub's Interesting Proposal (Good Omens)

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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

CS:GO Bomb Defuse Timer Countdown Animation

ALT: CS:GO Bomb Defuse Timer Countdown Animation

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Swapnil Hiremath 🍁🇨🇦@hswapnil.medsky.social · 4mo ago

one fun thing about using phenobarbital for seizures in ICU is that you can be as precise as you want (PK is predictable & levels turnaround fast) high precision usually isn't needed but if the neuro team wants me to hit a specific phenobarbital level in brittle SE, I'm on it 🫡. #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

Comparison of 8.4% Sodium Bicarbonate vs. 3% Sodium Chloride in Severe Hyponatremia: A Retrospective Cohort Study - PubMed

This study found that a single 50 mL dose of HTB more often resulted in obtainment of guideline-recommended post-intervention serum sodium goal concentrations than a 100 mL HTS dose. Additional studies...

pubmed.ncbi.nlm.nih.gov

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

a man with a stethoscope around his neck is sitting in front of a sign that says " only time will tell "

ALT: a man with a stethoscope around his neck is sitting in front of a sign that says " only time will tell "

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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

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Pet peeve: Research on pupillometry that only reports the neural pupil index (NPi) is worthless & will wind up in the ash heap of history. NPi is *proprietary* & calculated with a *secret* formula by *one* company's product. Does this seem like ideal scientific practice?...#1/2 #EMIMCC

note to self: use more IV nalbuphine it's supported by robust theoretical & clinical evidence I'm pretty sure the only reason we don't use it more often is due to our training and habits (habit-based practice, not evidence-based practice) esp. useful in patients with tenuous respiratory drive

Fresh blog on the HI-PEITHO trial 😁 🔊 ~18 mg alteplase over 7 hrs is safe (no ICH, no difference in bleeding rates) 🔊 Alteplase reduces the risk of cardiopulmonary decompensation and poor functional outcomes #1/2 #EMIMCC

it's hilarious watching people desperately try to apply the AHA/ACC risk stratification system to the HI-PEITHO trial HI-PEITHO was built off of the ESC risk-stratification system and it's impossible to map these patients onto the AHA/ACC classification. ESC is better. just use it.

Lars Mølgaard Saxhaug@load-dependent.eurosky.social · 4mo ago

missing sepsis - bad misdiagnosing another catastrophe as “sepsis” - also bad it almost makes me think that maybe we should specially train people how to identify and differentiate these disease processes and provide personalized care 🤔

The most dangerous thing you can have is a non-septic shock misclassified as septic shock. #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

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

when your post-CABG patient is in shock with a heart rate of 55 and you start pacing through the atrial wire at 88 b/m

a little boy is driving a red toy car down the street .

ALT: a little boy is driving a red toy car down the street .

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If you missed this, read it before the HI-PEITHO trial comes out on 3/28 I think the STRATIFY trial will be integral to understanding and applying the results of the HI-PEITHO trial 😁🤞

Fresh blog: STRATIFY trial for PE Peripheral tPA infusion is EQUALLY EFFECTIVE as compared to ultrasound-assisted thrombolysis Catheter-directed thrombolysis for PE is dead We can get the same benefits with peripheral tPA infusions (w/o procedural costs & complications)... #1/2 #EMIMCC

Fresh blog: Six reasons to stop relying on the NPi (neurological pupil index) 👁️ NPi is based on a secret, proprietary formula used by one company 👁️ The neuroICU field was somehow convinced that we're too stupid to understand pupillometry tracings, so we need the NPi...(#1/2) #EMIMCC

proposal: IV lacosamide loading in the ICU is safe in patients with asymptomatic 1st degree AV block (PR >200 ms) I encounter a lot of anxiety surrounding this, but the fear doesn't seem to be evidence-based Other drugs we use in ICU are much more likely to cause bradycardia

a man in a suit and tie is sitting at a desk and says who hurt you

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Lars Mølgaard Saxhaug@load-dependent.eurosky.social · 5mo ago

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....

Kaplan-Meier plot showing the relative bleeding risk between rivaroxaban and apixaban over 90 days, clear separation and clearly higher risk from rivaroxaban

Patient with pulmonary embolism develops mild hemoptysis: - Dont panic - Dont stop anticoagulation - Dont give TXA - Just continue anticoagulation Hemoptysis is an accepted symptom of PE. It’s usually due to mild capillary necrosis & not severe (not arterial).

a sign that says stay on target with a red line

ALT: a sign that says stay on target with a red line

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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

Dr. Timothy Fernandes, MD. MPH @drtimfernandes.bsky.social · 5mo ago

ScvO2 is so hot right now. About a decade ago we had a patient in shock with terrible echo windows. ScvO2 was high, so the team thought sepsis. Antibiotics failed. Autopsy showed MI. We had an M&M conference. Everyone was confused about why the ScvO2 misled us. What happened? … #1/2 #EMIMCC

a man in a suit and tie says what went wrong on snl

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The A-E categories are totally made up, based on retrospective data, difficult to apply clinical trials including data toward (ie intermediate-high risk spans multiple categories), and should not serve as the basis for determining whether an intervention is warranted.