𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊 Profile picture
zentensivist 😷 FOAMite 🌊 diuresis jedi 💦 leader of the rebel alliance ⚔️ resuscitationist 💉 humanist 😢 writer with aweful speling 😬 no COI 💰
Murid Salaf Profile picture Bharat Balan, MD, MS Profile picture medicalmoe Profile picture Alexander lamper Profile picture Hari Shankar Profile picture 11 subscribed
Dec 17, 2023 6 tweets 2 min read
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…
Nov 24, 2023 5 tweets 3 min read
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… 🧵 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!
Oct 27, 2022 5 tweets 3 min read
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? 🤣) ImageImageImageImage 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)

Oct 26, 2022 11 tweets 5 min read
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 ??)
Aug 17, 2022 8 tweets 4 min read
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
Aug 15, 2022 6 tweets 3 min read
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
Jul 24, 2022 8 tweets 3 min read
A 75YO human is transferred to your ICU from an outlying hospital 2/2 concerns regarding septic shock.

Generally healthy. History notable for fevers and neck stiffness.

Exam shows mild hypotension, nuchal rigidity, and nonfocal neuro exam (w/ apologies to The Neurologist).... Due to the time delay in transfer, blood cultures have *already* turned positive in 2/2 sets with gram pos cocci in clusters.

**Teaching interlude**:

Each blood draw generates 1 SET = 2 BOTTLES.

1/2 SETS with GPC is often contamination.

2/2 SETS implies true positive...
Jun 15, 2022 7 tweets 3 min read
hot take on the LOVIT trial of vitamin C... I'm probably going to regret this but I can't resist... as a preface, it seems that Marik's initial paper might have been fabricated - which may have pushed the field in the wrong direction for years. the VITAMINS trial largely halted the use of vitamin C... and surely nobody is going to use it now for sepsis.
medpagetoday.com/special-report…
Apr 28, 2022 14 tweets 5 min read
time for a fluid & electrolyte tweetorial 😝

an asymptomatic adult human presents with these findings... ImageImage should you institute therapy or repeat lytes?
Oct 7, 2021 11 tweets 5 min read
Waveform capnography! I've been meaning to cover this for years. Finally posted an IBCC chapter on it. The chapter is pretty long (filled with subversion, physiology, and zentensivism), so here is a thread with some key points.🧵
emcrit.org/ibcc/co2/ end tidal CO2 (etCO2) will ~always be lower than the arterial CO2 (b/c dead space dilutes CO2 as the patient exhales). the gap between the etCO2 and the arterial CO2 varies depending on lung function. in normal lungs, the CO2 gap is usually ~2-5 with an upper limit of ~10-15
Sep 20, 2021 12 tweets 8 min read
oh, the life & times of remdesivir! - let's review the bizarre trajectory we've taken with this medication! with emoji's to represent each study 🤣 we start with a retrospective series of patients treated with remdesivir under the banner of "compassionate use." most patients didn't die. this paper has so many flaws, at this point it's merely a case study in horrific research design 🤮 (commentary: bit.ly/2XBwnx1)
May 25, 2021 6 tweets 3 min read
fresh RCT on the effects of a continuous infusion of hypertonic saline for traumatic brain injury (#1/6)
jamanetwork.com/journals/jama/… patients were randomized to an infusion of 20% NaCl for 48 hours. as shown here, the infusion was successful at pushing sodium levels to the mid-150s, with nice separation between groups (#2/6)
Sep 23, 2020 18 tweets 13 min read
live tweeting: "Time's Up: Eliminating Sexual Harassment & Gender Inequity in Healthcare" by @SharonneHayes ImageImageImage Women may have different leadership styles than men. Countries led by women have had fewer issues with COVID-19 🔥
-@SharonneHayes Image
Sep 16, 2020 4 tweets 2 min read
if you don't immediately know why this paper is garbage, then read this explanation (bit.ly/3klwkek). in short, time-to-intervention studies are retrospective correlational junk which continue to infest the scientific literature (rantorial #1/4) the data from this study actually suggest that early antibiotics in pneumonia are *bad*, but early antibiotics in septic shock are *good*. this obviously isn't true -it merely serves as an illustration of what happens when you conflate correlation with causality (rantorial #2/4) Image
Sep 14, 2020 4 tweets 3 min read
three short chapters on gastrointestinal hypo-motility in critical care.
💣this topic often gets *ignored* until there's a serious complication
💣early attention to motility can avoid iatrogenesis & facilitate recovery...
(thread #1/4) ICU gastroparesis
🤮 manifests as tube feed intolerance (but don't assume that feeding intolerance = gastroparesis!)
🤮 a post-pyloric feeding tube can treat this nicely. otherwise erythromycin +/- metoclopramide
🤮 treat this- don't just watch/wait (#2/4)
emcrit.org/ibcc/gastropar…
Sep 5, 2020 4 tweets 3 min read
a fresh review article on pancreatitis in the Lancet is some hot garbage. as Eduardo rightly pointed out 👇, the bit on fluid resuscitation is nuts. but there are more errors, which merit a short #rantorial... 1/4 one RCT showed that delayed feeding was OK... in a population with mostly *mild* illness. the authors wrongly extrapolate this to *all* patients. esp for an intubated patient, there is no reason to delay feeding for 72 hours! #rantorial 2/4
emcrit.org/ibcc/pancreati… Image
Aug 18, 2020 5 tweets 4 min read
Tobin vs Gattinoni: Infinity War💣
Get some more popcorn 🍿
Let's start back at the beginning...
🥊Round #1: Tobin's original editorial casts shade on P-SILI & recommends our usual, conservative approach to intubation (rather than pre-emptive intubation)
bit.ly/3h7wx3r ImageImage Round #2: Gattinoni replies
🥊3 citations to support existence of P-SILI
🥊claims COVID patients have unusually good compliance based on observing hundreds of patients (no data)
🥊recommends using esophageal pressure swings as a trigger for intubation 🤡
bit.ly/3aAHGaA ImageImage
Aug 1, 2020 6 tweets 4 min read
👊Martin Tobin strikes again, with a painfully incisive editorial on whether COVID-19 is ARDS. this discussion is worth having, to debunk some mis-conceptions surrounding the concept of ARDS...(1/6).
(full article: bit.ly/39NzbZB) Image ARDS isn't a disease, it's a *syndrome* (an empiric grouping of abnormalities with no defined etiology). the utility of this syndrome has long been debatable. ARDS has evolved through a series of consensus definitions, which nonetheless remain profoundly flawed. (2/6) ImageImage
Jul 31, 2020 18 tweets 8 min read
Index thread linking together all the talks at #HRreloaded! In case you got lost in the tweet storm, you can scroll through this to find any talks you might have missed...
🧵 of 🧵's... @ThinkingCC on when to intubate the COVID patient
Jul 31, 2020 19 tweets 15 min read
Avoiding airway catastrophe!
When things go sideways, don't be passive
How can we harness a team appropriately?
- @drlauraduggan at #HRreloaded closed claims analysis: what patterns emerge?
10-12 teaching cases in the back are worth reading
- @drlauraduggan at #HRreloaded
Jul 31, 2020 10 tweets 10 min read
neuroPOCUS & trans-cranial doppler

- @ottawaheartrob at #HRreloaded folks figured out trans-cranial doppler using M-mode probes. amazing. this makes me feel really guilty for struggling with a 2D probe.
- @ottawaheartrob at #HRreloaded