josh farkas 💊

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

Agree, but this requires a system-level intervention.

I didn’t put much stuff in the chapter about exactly how to titrate the insulin gtt because its generally best to use your local insulin gtt protocol that folks are comfortable with.

Belmont is awesome 😁

The difference between an expert vs amateur DKA resus is really efficiency

Patients are overwhelmingly likely to do well regardless

Expert resus may accelerate resolution & avoid re-opening the gap

So there are other hills to die on

If your protocols work efficiently, there’s no reason to change

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

got it thanks🙏🙏🙏

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

YouTube video by EMSwami Blunt Cardiac Injury #emergencymedicine #criticalcare #trauma

Blunt Cardiac Injury
Suspect: blunt traumatic hemothorax, pulmonary contusions, esophageal/aortic injury
Not assoc w/ isolated sternal fracture
w/u: Tn and ECG - If either abnormal, admit to tele and get a comprehensive echo looking for wall motion abnormality

youtube.com/shorts/UTHbm...
#EMIMCC

my favorite is the "consistent carb diet" where you're allowed to have a lot of carbs, or a little carbs, but it has to be consistent across the day 😂

it's hard to fight city hall.

and nearly all of this BS won't really hurt people, it just delays their recovery

that's not great, but there are other hills to die on 🤷‍♂️

Vermont health officials alarmed by shift from opioid abuse to stimulants Vermont health officials say the state is entering a new wave of the drug crisis.

we're seeing *lots* of cocaine & methamphetamine use, especially via inhalational routes

presentations vary, including:

🥵 acute agitation/psychosis
🥵 seizures
🥵 vascular events, esp in young people (stroke, MI)

Local news www.wcax.com/2025/10/02/v...

IBCC chapter emcrit.org/ibcc/symp/ #EMIMCC

#idboardreview 65 F HTN, smoker, no travel, no animal exposure, recurrent UTI on nitrofurantoin presents w/ 3d of illness, 101F, dry cough, dyspnea, now in respiratory failure. b/l crackles, BAL 12% eosinophils. dx? #medEd #idmedEd #IDtwitter #idsky pic for Ref only

EMCrit 409 - Pulmonary Embolism (PE) Update 2025 with @klinelab (Jeff Kline)
We explore some of the questions raised by the recently posted PE malpractice case.
When can you PERC???
Should you give heparin at the same time as your lytics?
and so much more
[#FOAMed for a bit]
emcrit.org/409

Agree, but you can order a regular diet and allow the patient to select their own carb-restricted foods.

Ordering a regular diet is simply giving the patient power to order whatever they want from the menu.

a man in scrubs is eating a piece of food while sitting in a hospital bed . ALT: a man in scrubs is eating a piece of food while sitting in a hospital bed .

be kind and give your patients a REGULAR DIET

caffeine-free diets ➡️ caffeine withdrawal

sodium-restricted diets aren't evidence-based (use diuretics to balance volume)

treat hyperglycemia with insulin (not by artificially restricting carbs)

(renal diet for hyperkalemic renal failure = exception)

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yeah I agree, if the heart rate is generally running <130s I’ll let it run free

sometimes shifting pressors to phenyl/vaso can buy you a little reduction in HR

if consistently >130 I’d probably add amiodarone

not aware of any good data on this

🚨🔊 New episode out today! Case files at KUMC!

A 26 year old non-smoking man who immigrated from India and now lives in the mid-west US presents with a generalized tonic-clonic seizure in the setting of 6 months of cough and dyspnea. Here is the initial CT

#Pulmonary
#CriticalCare
#MedicalEducation

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

These sort of guidelines are actually holding back the field of DKA from making progress

because UpToDate and most other sources will mirror their recs off the guideline without much critical evaluation

I'm pretty sure what they're trying to say is that the bicarbonate may remain low after the ketoacidosis has resolved due to a hyperchloremic NAGMA resulting from NaCl administration. I've read a ton of these reviews on DKA and most reviews will include a statement to this effect in this location 🤷‍♂️

a man in a black shirt is standing in front of a fire and the words do it ALT: a man in a black shirt is standing in front of a fire and the words do it

if you’re getting a CT chest for a critically ill patient in respiratory failure of unclear etiology, it should be a CT angio to evaluate for PE (& other stuff)

sometimes being thorough is more effective than being smart

also, contrast allows evauation of cardiac chamber size & IVC reflux

the guidelines also state that NAGMA isn't a big deal

but you're not supposed to stop the insulin drip until the bicarb is >18

if NAGMA prevents you from shutting off the insulin infusion, it will keep patients on the drip longer - which *absolutely* matters (time, $$$, bed utilization).

I don't have time to catalog every error in the guidelines, but let me just mention a few.

the guidelines seem to lack an understanding of basic acid-base principles

for example, it says here that hyperchloremic metabolic acidosis from NaCl causes an elevation in anion gap.

nope, that's wrong.

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/

One factor driving health disparities is how so many doctors are attracted to the biggest & best resourced hospitals.

Problem solved, you're welcome.

if you want to up your game from a random cortisol, you can do a combination of random cortisol plus simultaneous ACTH and DHEA-S levels.

ACTH & DHEA-S levels may be sendouts so they may take some time to come back

but it's arguably more info than an isolated cortisol level 🤷‍♂️

Truth, I don't think I've seen <5 pred either 😂

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OMG anyone who thinks there is a country on this planet that doesn’t use acetaminophen 🫢

a man in front of a microphone with the words it 's just so efficient below him ALT: a man in front of a microphone with the words it 's just so efficient below him

my preference is to give dexamethasone 6 mg x1 (covers for adrenal insufficiency) & immediately perform an ACTH stim test

(dex doesn't interfere w/ measuring cortisol)

this usually allows exclusion of adrenal insufficiency within hours, re-focusing the evaluation on other possibilities

thoughts?