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𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊

@PulmCrit

Dec 17, 2023

how to place a consult: you MUST understand the five stages of consultant grief.

once you can understand this painful and natural process, requesting consults will make a LOT more sense

buckle up, it can be a little rough…

🧵 1/6…

stage 1: denial

- You dont need a consult.
- You called the wrong service.
- 18 years old? consult pediatrics
- I’m not actually on call now
- Everything’s fine, just walk it off…

stage 2: anger

- you should have consulted us earlier/later
- you should have checked this test before calling us
- you’re a terrible doctor/student/human being

Read 6 tweets

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊

@PulmCrit

Nov 24, 2023

https://twitter.com/fluid_academy/status/1727713145026760810

I’m gonna myth-bust this myth-busting slide on the use of bicarb.

the slide says to use bicarb for hyperkalemia “only in cardiac arrest??”

there is evidence on this and I think it’s possible to make a more accurate statement… 🧵

https://twitter.com/fluid_academy/status/1727713145026760810

the problem is that people ask the wrong question: “does bicarb work for hyperkalemia”

bad question.

any systemic analysis based on this question is a failure.

this would be like asking “does sodium chloride work for cerebral edema”

well, it depends… on the concentration!

hypertonic sodium bicarb (in the USA = 50 mEq in 50 cc) doesn’t work for hyperkalemia

this has been tested in RCTs and it doesnt work

hypertonic fluids pull fluid & K out of cells (“solute drag”) and this prevents hypertonic bicarb from working for hyperkalemia

Read 5 tweets

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊

@PulmCrit

Oct 27, 2022

another haloperidol thread 😃

this fresh pro-con debate on the use of IV haloperidol is important reading (even for folks not working in the emergency department).

(is there any neuroactive medication that people don't have passionate opinions about? 🤣)

from the ICU perspective, the recent AID-ICU trial shows that IV haloperidol is safe in the ICU.

of course, this *assumes* that it's used wisely (with attention to electrolytes and QT)

(hint: when in doubt, give IV magnesium along with the haloperidol)

https://twitter.com/PulmCrit/status/1585351146482593792?s=20&t=SxsUawXWJZmV2Oee5rjNZw

@SkylerLentz

as @SkylerLentz et al. discuss, haloperidol is generally preferred over benzodiazepines for agitation in the ICU.

as a general rule of thumb, *any* time you're tempted to use benzodiazepines in the ICU - consider whether haloperidol might be a better option.

benzos are a trap:

Read 5 tweets

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊

@PulmCrit

Oct 26, 2022

hot take on the AID-ICU trial of haloperidol for management of delirium in ICU 🔥

this is the largest MC-RCT to date on haloperidol for treatment of delirium (in comparison, MINDS enrolled 192 patients in the haloperidol group).

nejm.org/doi/full/10.10…

55% of patients had hyperactive delirium.

this is much better than MINDS (which contained ~90% hypoactive), but probably still not ideal.

(at this point, does anyone actually think that haloperidol helps with hypoactive delirium ??)

other than dilution of the patient population by patients with hypoactive delirium (who are unlikely to benefit & might conceivably be harmed by over-sedation), the methodology seems pretty solid.

Read 11 tweets

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊

@PulmCrit

Aug 17, 2022

I think this paper by the Nielsen group on the use of CT scans to neuroprognosticate after cardiac arrest may be a game-changer.

But it will take a few tweets to explain why... 🧵

pubmed.ncbi.nlm.nih.gov/35931271/

prognostication after cardiac arrest involves a structured series of tests performed over time.

this may vary a bit between patients and institutions.

most often, decisions center around the trifecta:
🔺serial clinical examination
🔺continuous EEG
🔺MRI

MRI is the weak link:

🖇️ least robust evidence
🖇️ interpretation is subjective
🖇️ logistically challenging (eg pacemaker)

MRI can help if there is *no* anoxia, or if there is an unexpected *alternative* dx.

MRI isn't great at sorting out bad anoxia from moderate anoxia.

Read 8 tweets

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊

@PulmCrit

Aug 15, 2022

I think it's time for a difficult discussion, folks.

Let's talk about CSF lactate 🫣

CSF lactate has been shown to be *superior* to traditional CSF studies in sorting out viral vs. bacterial meningitis in several studies & meta-analyses...

a subset of patients with viral meningitis will initially have a *neutrophilic* pleocytosis.

this can lead to unnecessary admissions & antibiotics

some patients are subjected to repeat LPs 😩

a low CSF lactate could avoid all of this, allowing patients to go home from the ED

CSF lactate measurement is recommended in guidelines from the United Kingdom, Europe, and France.

(it's not recommended in the ID society of America guidelines, but they're from *2004* and require revisions)

Read 6 tweets

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𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊

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