josh farkas 💊

resident letting the first 10 drops of the lumbar puncture fall on the bed so they get a champaign tap

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

Insulin bolus typically not necessary in DKA but, consider if:

Delay in getting insulin drip from pharamacy.

Severe acidosis: reach therapeutic levels faster + fix the acidosis faster

Bolus dose: 0.1 U/kg

youtube.com/shorts/pYybS...
#EMIMCC

1) acetazolamide for iatrogenic contraction alkalosis is standard tx IMHO (most drugs are "off label") along with K repletion etc

2) PO acetazolamide probably fine, great bioavailability

3) prevention with amiloride is great, I love amiloride

4) triamterene is maybe nephrotoxic so less of a fan

yes 💯

this formula is clearly incorrect based on my high school science education

you can't add a pressure and a velocity together because they have different units (mm, cm/s)

if the units don't work, the formula must be invalid

it works to evaluate the immediate effect of a bolus because renal compensation doesnt have time to take effect within such a short timeframe

this is one of the few situations where the formula works well (it also works in SIADH or a DDAVP clamp)

it's wild how badly people dose hypertonic therapy

60 ml of 23% is equivalent to ~500 ml 3%, so this article makes no coherent sense

best approach: figure out the sodium change you want and calculate the hypertonic dose

math sets you free from dozens of contradictory consensus statements #EMIMCC

When we intubate someone we assume responsibility for all of their vital functions, no matter how mundane 💯

repeated PRN doses could eventually cause trouble if nobody is paying attention to the Mg level. Often these PRN Mg q12hr orders are put in and nobody pays a ton of attention to them from the physician side.

are you using a DEFCON-based strategy to manage bowel motility in hospitalized patients?

having a clear, evidence-based treatment strategy improves efficacy & saves time

you don't need to redesign the wheel for every patient

& helpful to avert thermonuclear war

emcrit.org/ibcc/constip... #EMIMCC

it’s not uncommon for beta-blockers to kill patients with thyroid storm.

this is well described in published literature.

people present with subacute illness, walk into the hospital, and they’re coding 6 hours later.

this deterioration is usually mis-attributed to the thyroid storm (not the tx)

meh, failing to diagnose serotonin syndrome really just spares you 30 minutes of debating cyproheptadine on rounds 😂

I'm betting 1000% they got better with supportive care alone, which is what happens in serotonin syndrome.

My message to EM docs:

If you can diagnose thyroid storm, give basic thyroid storm drugs (thionamide, steroid, iodine etc), identify/treat underlying issues (eg sepsis), and provide standard hemodynamic resus you're done an insanely amazingly great job! You're done!

(Just forget bbl)

a man in a suit and tie is saying i just want it to stop . ALT: a man in a suit and tie is saying i just want it to stop .

There is no evidence to support B-bl for sinus tachycardia in thyroid storm

This practice has been wrongly extrapolated from the treatment of ambulatory patients with thyrotoxicosis

ALWAYS TREAT THE CAUSE OF SINUS TACH

Sinus tach is like a fire alarm. Beta-blocking it is silencing the alarm.

Fresh Blog: Mythbusting the use of beta-blockers for sinus tachycardia in thyroid storm

This is one of the most dangerous & pervasive myths currently in circulation about acute care

B-bl commonly precipitate shock or even arrest in these patients...(#1/2)

blog: emcrit.org/pulmcrit/tst... #EMIMCC

@bradspellberg.bsky.social and other ID gurus -

Does this look OK to you?

Any critiques and/or additional thoughts you would pass along to front-line clinicians about implementing this regimen in real life?

(disclosure: my hatred of ampho-induced AKI runs deep)

emcrit.org/ibcc/cryptoc...

Updated the acute ischemic stroke chapter based on 2026 ASA/AHA guidelines

Chapter focuses on supportive care (*not* who gets lysis/EVT)

This has not changed very much

Top blue numbered section is designed to be used as a checklist when you settle these pts into ICU

emcrit.org/ibcc/ais/ #EMIMCC

yeah overall it seems like a good guideline to me

and HOLY MOLY the AHA/ACC guidelines have gotten so much more readable and concise, they're almost up to the level of a european guideline 😂

yeah. most articles on this aren’t great because it’s kinda beyond their area of focus. but I was hoping for something better from the big fancy new guideline.

keep giving random drugs until the swelling subsides. (which will happen naturally over time irregardless) 😂

Thrombolytic-induced angioedema is bradykinin-mediated.

Steroids/epinephrine/antihistamines don't seem to work.

Epinephrine risks causing HTN & promoting intracranial hemorrhage post-tPA with no real benefit.

My approach to this problem is here: emcrit.org/ibcc/ais/#th...

The new 2026 AHA/ASA stroke guidelines include this table 👇 for the management of thrombolytic-induced angioedema.

There is NO discussion or any additional text about this topic.

I find this to be insufficient, not evidence-based, and potentially confusing... #1/2 #EMIMCC

#idboardreview 20 F cough, F, fatigue didnt improve w/azithro, no travel,+gardening: wbc 17k 90%pmn, Ct patchy nodules biopsy necrotizing granulomas stain+Aspergillus. Growing up, pt &her brother had several episodes of cervical lymphadenitis. How to make dx of possible genetic dz? #idsky #idmeded

YouTube video by EMSwami Roc + Prolonged Paralysis #criticalcare #emergencymedicine #intubation

Prolonged paralysis w/ rocuronium is an advantage
-Once we decide to intubate, patient's getting tubed
-W/sux, can end up in awake pt while trying to intubate if 1st/2nd attempt fail
-W/ roc, plenty of time if you run into a challenging airway

youtube.com/shorts/HXtN7...
#EMIMCC

reminder to liberally check carbon monoxide levels during snowmageddon

CO levels can be measured on venous blood along with routine labs (no need for a separate arterial puncture)

emcrit.org/ibcc/co/ #EMIMCC

a close up of a human eye with brown eyes ALT: a close up of a human eye with brown eyes

does anyone know of a good iphone digital pupillometry app that doesn't store data in the cloud (i.e., doesn't have patient confidentiality issues)?

end-stage academia:

how to game the system to score more grants and publications

this is ultimately a zero-sum rat race that doesn't help patients or science

hi, intesivist here.

we dont use sepsis screens.

sepsis screens use us.

the word level is on a black background with a light coming out of it ALT: the word level is on a black background with a light coming out of it

more on DCOS & catatonia: emcrit.org/ibcc/cataton...

catatonia is an important dimension of mental status abnormalities

understanding catatonia allows you to manage some strange phenomena (e.g. pseudocoma, propofol frenzy, haldol-refractory ketamine-sensitive agitation)

#EMIMCC