Yusuf Malik

A tricky thing about modern society is that no one has any idea when they don’t die.

Like, the number of lives saved by controlling air pollution in America is probably over 200,000 per year, but the number of people who think their life was saved by controlling air pollution is zero.

#creatine a thread Creatine is formed naturally in the liver pancreas, kidneys and the brain and is found in every cell of the body.1/n

The death of expertise...

The image is a black-and-white political cartoon depicting a man in a suit standing behind a counter labeled "Republican Platform." He is holding a bottle labeled "Untaxed Whiskey, 20¢ Gal." in one hand and a piece of cloth labeled "War-Taxed Common Cloth, Tariff 84%" in the other. Above the counter, a sign reads, "If you don’t see what you want, ask for it." The cartoon, signed by W.A. Rogers, appears to satirize the Republican Party's economic policies, highlighting the disparity in taxation between luxury items like whiskey and essential goods like cloth.

In 1890, the Tariff Act came into place in the United States. It placed tariffs on imports of up to 50%.
While touted as a way to build American industry, there was also the hope it would force an annexation of Canada. It backfired.
Let's learn more.

🧵1/10

Jornal Nacional showing the truth.

Clinicians were generally less concerned about sepsis among patients with abnormally low temperature and WBC count than patients with abnormally high temperature and WBC count #idsky #EMIMCC #medsky

1/ 7th Day of Pharmacy Advent
Let’s talk about anticoagulation in cirrhosis – a nuanced topic where balance is critical. Pts w/ ESLD face unique challenges d/t unpredictable pro- and anticoagulant changes. Let's dive deeper 👇
#medsky #pharmsky #GPsky #HMsky #emimcc #nursesky

ICU Resuscitation Thoughts:

Every 2 years this time of the year I have to provide my hospital-employer with proof of my recertification in ACLS. I usually take an on-line course which one can finish in a few hours. Sadly, this biennial ritual is also a reminder that we keep following the same #CPR

Learning how to have an emergent, effective, and compassionate family meeting on goals of care is as important a skill as intubation or chest drain. Needs as much training and practice. Need to know their wishes and expectations to guide them forward.

BRASH syndrome ECG:
- subtle peaked T-waves from hyperkalemia
- bradycardia is *disproportionately* severe, as compared to the extent of hyperkalemia-induced morphology changes

(more on BRASH: emcrit.org/ibcc/brash/)

(ECG credit: ecg.bidmc.harvard.edu/maven/dispca...) #ECGsky

Ventricular arrhythmias CONTENTS approach to wide-complex monomorphic tachycardia Diagnostic approach to wide complex tachycardia [1] Consider pretest probability for VT [2] Compare to old ECG if available [3] Initiation of ...

Pulmcrit has a bit on this topic but of course every patient encounter has unique challenges
emcrit.org/ibcc/storm/#...

Interesting. I think in these cases the jury is out but the question about the role of epi is valid. Some would say Esmolol or maybe lidocaine? While trying to teleport to cath lab? Tough patient

Frostbite or snake bite? My mistake 😂

Nice nibble of revision for frostbite management. @tshanahan0584.bsky.social you are probably seeing loads of this?

Super interesting topic. Were you successful in your defib, but they would quickly devolve back to VT/VF? Or did the VT/VF persist despite shocks? How was the ECG before arrest, any STEMI/OMI?

That's interesting! Honestly I'm 100% sure they aren't recommending EMS to insert a-lines routinely in shock, but I think we can use this info to improve decision making in the ED and in-hospital critical care setting.

Of course BlueSky is a bit glitchy.

It would be like if you invited 10 people to dinner but 1000 showed up and then were like but wait why isn’t there enough pasta and did you think about making paella and what’s in this salad anyway oh and by the way a few of us are vegan and can’t eat any of this

I read such research more as a story rather than like a guideline. Many UK HEMS services routinely provide pre-hosp crit care interventions and so they have a fairly unique viewpoint to research critical illness! We might then try and extrapolate the physiology to our own patients wherever they are.

Just realised that the authors touch on this idea at the end of their Discussion. I think overall I would say that NIBP isn't best at detecting radio-femoral discrepancy ... But rather if we have escalating vasopressor requirements + cool (?mottled) fingers it's worth going femoral!

I suppose in that situation brachial (NIBP) may be better as it's more central? I wonder if the difference relates to the patients and underlying pathologies, pre-hospital and undifferentiated pathologies vs in the ICU and on pressors? @icmtim.bsky.social will probably know.(2/2)

Thanks for sharing this interesting article. I don't think they contradict each other, I think they each explore useful questions! I've seen other data (plus personal anecdotes) of radial art line pressure greatly underestimating the true pressure when on high doses of pressors. (1/2)

You only have a fixed number of good decisions in a day.

This concept, aka decision fatigue is incredibly important in thinking about allocating our decision making cognitive effort. If you're involved in high-stakes decision making, failing to acknowledge this reality can be catastrophic.
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This would also give you time to pre-ox, get some monitoring on and vitals, before paralysis. Safer for patient and for nurses/team members restraining and trying to get a line in.

Is it time to reframe resuscitation in trauma? Trauma remains a significant cause of mortality and morbidity. Non-compressible torso haemorrhage is one of the key drives of these mortality data. Our contemporary management has focused on damage co...

"In this paper, we suggest that perhaps more consideration should be given to the diastolic blood pressure in bleeding trauma patients. The diastolic blood pressure is critical for coronary perfusion, and in turn the cardiac output responsible for cerebral blood flow."
#EMIMCC

Non-invasive versus arterial pressure monitoring in the pre-hospital critical care environment: a paired comparison of concurrently recorded measurements - Scandinavian Journal of Trauma, Resuscitatio... Background Blood pressure monitoring is important in the pre-hospital management of critically ill patients. Non-invasive blood pressure (NIBP) measurements are commonly used but the accuracy of stand...

Non-invasive BP measurement overestimated SBP and MAP at low values and underestimated them at high values. When BP really matters get an art line.
sjtrem.biomedcentral.com/articles/10....
#EMIMCC

JC: Small versus Large-Bore Thoracostomy for Traumatic Hemothorax. Traditionally, large-bore chest tubes have been standard for managing haemothorax, but smaller tubes are now proving just as effective in stable patients, with added benefits like reduced pain and few...

Small vs large chest drains for haemothorax. How low can we go? (A - prob smaller than you think).
#FOAMed
@stemlyns.bsky.social www.stemlynsblog.org/jc-small-ver...

JC: Small versus Large-Bore Thoracostomy for Traumatic Hemothorax. Traditionally, large-bore chest tubes have been standard for managing haemothorax, but smaller tubes are now proving just as effective in stable patients, with added benefits like reduced pain and few...

St Emlyn's blog on SRMA for <14F Vs >20Fr chest tube for traumatic HTx.
1. Small bore is probably fine in stable patient
2. Not enough data to change practice for most severely injured / in extremis.

Worth a read #EMIMCC

Radial arterial lines are the default in most 🇬🇧 ICUs but can be wildly inaccurate in cases of profound shock.

These pics are taken seconds apart, after inserting a Femoral PiCCO line, systolic BP 121mmHg higher!!!

I’ve seen big discrepancies before but nothing of this magnitude! 😲

1/

PulmCrit: A-lines in septic shock: the wrist versus the groin Historically, emphasis has rested on the distinction between noninvasive versus invasive BP (e.g., cuff pressure vs. radial arterial pressure).  Attention focused on whether noninvasive oscillometric ...

In those super sick patients on high doses of pressors, keep it in your back pocket!

Nb:
And no the transducer was not on the floor…

@pulmcrit.bsky.social has a great blog post on the topic for anyone wanting to learn more 📖

emcrit.org/pulmcrit/a-l...

2/2

a cartoon drawing of a mountain with the sun shining through it Alt: a cartoon drawing of a mountain with the sun shining through it, a dinosaur climbs the mountain and roars

Critical care intubation hills I’m willing to die on (collating an occasional series from elsewhere).
Each hill is based on experience and other people’s research (I claim no other expertise) #EMIMCC #PCCM #AnSky