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𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 💊 Profile picture
𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 💊
@PulmCrit
zentensivist 🧘‍♂️ FOAMite 🌊 diuresis jedi 💦 leader of the rebel alliance ⚔️ resuscitationist 💉 writer with aweful speling 😬 no COI 💰
11 subscribers
Oct 26 • 6 tweets • 4 min read
Critical interactions for the critical care cardiologist: An anthology of the tortured pharmacist's department

- @TaniaAhuja at #critcarecards24 Image @TaniaAhuja who should get AV nodal blockers?

Diltiazem is contraindicated in shock.

**If you don't know the EF, may avoid.**

Diltiazem and riveroxiban may interact as well.

- @TaniaAhuja at #critcarecards24 Image
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Oct 26 • 9 tweets • 4 min read
Low slow and trying to crash

CCB & Bbl intoxication.

Getting things done is tough! A really sick CCB/BBl intoxication challenges this.

- @emcrit at #critcarecards24 Image
Image @emcrit Start with calcium, although it probably don't do a ton. May follow this with a calcium infusion if there is sufficient IV access.

- @emcrit at #critcarecards24 Image
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Oct 25 • 4 tweets • 2 min read
Why do I deviate from ACLS?

- @mdonnino at #critcarecards24 Image @mdonnino Do you resume CPR after shock? Yeap.

In 2005 the algorithm changed from stacked shocks to a single shock followed by waiting for 2 minutes to see what is going on.

No solid evidence that this was the correct approach.

- @mdonnino at #critcarecards24 Image
Oct 25 • 6 tweets • 4 min read
More on RV failure:

Acute RVMI: loading can be helpful because we want to raise the RV pressure higher than the PA pressure to cause blood to flow downhill.

- @Chrisotpher Barnett at #critcarecards24 Image
Image Chronic pulmonary artery hypertension: RV is *chronically* adapted

Volume loading may help push patients into the RV death spiral.

- Chrisotpher Barnett at #critcarecards24 Image
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Oct 25 • 7 tweets • 3 min read
1st talk: RV dysfunction by @Sam_Brusca at #critcarecards24

RV contracts in multiple mechanisms.

LV contraction indirectly contributes 40% of the stroke volume of the RV! Image
Image - RV-PA coupling may fail with RV dilation, but this is difficult to assess at the bedside

- @Sam_Brusca at #critcarecards24 Image
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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