Anthony Lau, PharmD BCPS

unpopular opinion: if ICP is unequivocally elevated due to cardiac arrest (eg >25mm), that suggests severe brain injury with a poor prognosis, no matter what you do.

this explains why trials of higher MAP targets after cardiac arrest (eg BOX trial) are all neutral. #EMIMCC

YouTube video by EMSwami Head of Bed Elevated for Airway Management #emergencymedicine #criticalcare #intubation

Bed-Up-Head-Elevated (BUHE) positioning is an easy, effective way to increase safe apneic time and reduce intubation related complications PMID: 26866753

youtube.com/shorts/BnZz0...

#EMIMCC

CDI recurrence affects about 14% to 16% of patients with CDI, and the risk of recurrence increases with each CDI episode
🆕💫🌟 JAMA Insights
Recurrent Clostridioides difficile Infections
🟢Epidemiology and Risk factors
🟢Diagnosis
🟢Treatment
#IDSky #EMIMCC
jamanetwork.com/journals/jam...

Wow! This is pretty innovative!! 🤯

YouTube video by EMSwami HypoK in DKA #emergencymedicine #criticalcare #dka

DKA Tip #3: HypoK the big killer
-All DKA patients total body K depleted
-Some p/w hyperK due to acidosis shifting K
-K < 3.5, replete prior to starting insulin. > 3.5 start insulin + K together
-Skip bolus: no faster resolution of DKA but incr risk of hypoK

youtube.com/shorts/PK_qF...
#EMIMCC

YouTube video by EMSwami Ketones in DKA #emergencymedicine #criticalcare #dka

DKA Tip #2: Urine dip can mislead
-Body produces 3 ketones: acetoacetate, acetone + beta hydroxybutarate (BHB0
-UA only looks for acetoacetate. BHB dominates in early in DKA
-If worried about DKA, get a chem/blood gas for bicarb + pH + serum BHB

youtube.com/shorts/3KnuI...
#EMIMCC

Hot take:

You WANT the #creatinine to go up while diuresing in #cardiorenal syndrome AKI.

It’ll come back down when they’re better.

It’s a feature, not a bug.

#Medsky #Nephsky #cardiosky #cardiology #criticalcare @pulmcrit.bsky.social @imcrit.bsky.social #AKI #heartfailure #diuresis

YouTube video by EMSwami Insulin in DKA #emergencymedicine #criticalcare #dka

Role of insulin in DKA isn’t to drop sugar, it’s to shut of ketogenesis + close AG
-Don't stop insulin just because glucose hits 250 mg/dl
-Stop when AG closes, acidosis mainly resolved (bicarb greater than 18), long acting insulin on board + glucose controlled

youtube.com/shorts/z7prN...
#EMIMCC

a close up of a man 's face with the word smoooooth written on it . ALT: a close up of a man 's face with the word smoooooth written on it .

pharmacokinetics trick:

let’s say a med (eg metoprolol) is used q12hr as an outpatient

if you’re worried about causing instability, you *can* cut the dose in half and give it q6hr

there is no law that it MUST be given q12hr

smaller intervals = smoother effect & greater titratability

#EMIMCC

Sad Sad Bean GIF ALT: Sad Sad Bean GIF

normal mentation *doesn't* indicate adequate systemic perfusion

especially in cardiogenic shock, people can mentate well despite terrible CO & systemic perfusion

poor mentation is sometimes an early sign of *septic* shock, but often a very late indicator of other shock states #EMIMCC

Fresh blog: Six pearls on heparin-induced thrombocytopenia (HIT) in 2025

💎 enoxaparin causes 10x less HIT than UFH

💎 HEP score

💎 approach to intermediate 4T score?

💎 rising use of DOACs

💎 autoimmune HITT

💎 IVIG for immediate inhibition of HIT antibodies

blog emcrit.org/pulmcrit/hit... #EMIMCC

a woman in a checkered shirt says way too much sugar in a kitchen ALT: a woman in a checkered shirt says way too much sugar in a kitchen

Updated the IBCC DKA chapter 🍭

Biggest changes were organizational, there is now a pretty clear & streamlined 8-step guide

Biggest content change was a rewrite of the definition of DKA (but - spoiler alert - the definition remains unclear & controversial)…

emcrit.org/ibcc/dka/#top #EMIMCC

YouTube video by EMSwami Reduced Dose Insulin in HyperK #emergencymedicine #criticalcare

IV insulin is a backbone tx in hyperK
Standard: 10 units IVP w/ dextrose
2021 meta(PMID: 33993515) looked at 10 units vs < 10 units
No difference in reduction in serum K.
Reduced risk of hypoglycemic + severe hypoglycemic events w/ reduced insulin dose

youtube.com/shorts/Sz9Zy...
#EMIMCC

https://diabetesjournals.org/care/article/47/8/1257/156808/Hyperglycemic-Crises-in-Adults-With-Diabetes-A

"consensus" guideline on the management of DKA & HHS

with ZERO input from:
- anyone in emergency medicine
- anyone in critical care
- anyone in hospital medicine

the guidelines (published in 2024) contain many antiquated practices and big errors... 🧵#1/3 #EMIMCC

pubmed.ncbi.nlm.nih.gov/39052901/

Experience Lasting Moments, a #fundraising event with stunning #photography & limited-edition prints supporting TWCC’s #palliative care work in South Asia

📅 Oct 25: Join us in Abbotsford, BC! lnkd.in/gZB98e8T

🌐 Everywhere else? Our online Square-Print Sale Oct 15–30 twoworldscancer.ca/cart

Use of Phenobarbital for Treating Alcohol Withdrawal This quality improvement study evaluates the implementation, clinical outcomes, and safety of an electronic health record order set for intravenous weight-based phenobarbital loading for treating alco...

New study supporting phenobarb monotherapy for EtOH withdrawal😍

We’ve been seeing more pts with *combined* withdrawal lately (eg opioid + EtOH)

IMHO phenobarb is esp useful in complex withdrawal to tx EtOH w/d, avoid delirium, and avoid excessive GABA #EMIMCC

#1/2

jamanetwork.com/journals/jam...

a woman is holding a crystal ball with the words saw that coming written below her ALT: a woman is holding a crystal ball with the words saw that coming written below her

NLR isn't perfect, but it's a whole lot better than WBC

it can be an early signal of serious trouble

or, if NLR is normal, it argues against sepsis (look for some other problem)

NLR-blind clinicians will think you're a genius 😆

full discussion of NLR here:
emcrit.org/pulmcrit/nlr/

proposal:

all types of bradykinin-mediated angioedema involve a common vicious spiral 👇

tranexamic acid or aminocaproic acid should be universally effective in blocking this cycle & aborting attacks

there's no need for super-expensive drugs (icatibant et al.)

thoughts? criticism? #EMIMCC

"bUt tHe WhiTe cOuNT iS nOrmAL"

I see this pattern of laboratory evaluation almost every day in the ICU

anyone involved in evaluating acutely ill patients must be able to recognize this evolution, like the face of an old friend

what is going on here? #EMIMCC 🧵 #1/5

YouTube video by EMSwami Volume Load in Sick Asthma #emergencymedicine #criticalcare

Don’t forget to fluid load in sick asthma
-Huge insensible losses from incr RR + WOB
-If need intubation, pos pressure vent results in incr intrathoracic pressure dropping pulmonary venous return ➡️HD collapse
-Load early w/ 20-30 cc/kg of crystalloid to avoid

youtube.com/shorts/mbOzE...
#EMIMCC

https://pubmed.ncbi.nlm.nih.gov/33653974/

https://pubmed.ncbi.nlm.nih.gov/33653974/

updated IBCC chapter on anaphylaxis, some new additions:

🆕 methylene blue for anaphylaxis refractory to epi & fluid

🆕 sugammadex for anaphylaxis 2/2 roc or vec

🆕 nebulized epi (in combination with IV) for upper airway edema? Don't bank on it but might help?

(emcrit.org/ibcc/anaphyl...) #EMIMCC

a man in a suit is drinking from a cup that says ' mrs. pepper ' on it ALT: a man in a suit is drinking from a cup that says ' mrs. pepper ' on it

Short skytorial about a fresh IBCC chapter covering all things methylxanthine-related (caffeine & theophylline).

This is a niche topic that we don't encounter in everyday practice, but it ties together some loose ends.

(chapter is here: emcrit.org/ibcc/caffeine/) #EMIMCC

📊 See the figure below to review antifungal coverage.

Frontiers | Ketogenic diet treatment for super-refractory status epilepticus in the intensive care unit: feasibility, safety and effectiveness Background and aimsTo investigate the feasibility, safety and effectiveness of the ketogenic diet (KD) for super-refractory status epilepticus (SRSE) in the ...

www.frontiersin.org/journals/neu...

KD can alter albumin levels, affecting drug levels. Drugs highly bound to albumin (e.g. clinda, doxy, phenytoin, valproate, warfarin, diuretics, NSAIDs) may have altered free concentrations due to KD-induced changes in albumin/fatty acid binding, potentially impacting therapeutic effect & toxicity

a man is sitting at a table with a plate of food and a cell phone with a pizza on it .. ALT: a man is sitting at a table with a plate of food and a cell phone with a pizza on it ..

What does this mean re: drugs? Switch diluent to NS from D5W, no propofol due to disrupting carb:fat ratio and balance, avoid crushable tabs and oral liquids due to sugar in syrups & be careful of highly protein-bound drugs! 🤔

- MOA: ↓carbs, ↑ketones, modulate neurons & neurotransmitters, inhibit mTOR, ↓excitatory signaling

- AEs: GI intolerance, metabolic acidosis, hyperlipidemia, hypoglycemia, lyte disturbances

- data promising but limited...no RCTs yet. Multidisciplinary care & close monitoring essential

a baby is smiling in front of a sign that says when your coach tells you that one of your favorite snacks is low on carbs ALT: a baby is smiling in front of a sign that says when your coach tells you that one of your favorite snacks is low on carbs

Learnt something new today! Ketogenic diet (KD) in super refractory status epi!

There's some emerging data suggesting KD may help adults w/ SRSE...based mostly on small icu studies & peds data. Case series report 70-85% SE resolution often w/in 2-5 days of ketosis #medsky #pharmsky #EMsky #neurosky

YouTube video by EMSwami Andexanet Alfa + Thrombembolism #emergencymedicine #criticalcare

Time to Ditch Andexanet Alfa?
-ANNEXA-1: No mortality benefit, incr VTE
-Real world data: Rech 2025 (PMID:40700941) no improved outcomes, 9% incr VTE w/ andexanet alfa (NNH = 11)

Mounting evidence that andexanet offers no benefit while increasing complications

youtube.com/shorts/7DGcv...
#EMIMCC