@emswami.bsky.social
EM doc | Resuscitationist | Medical Educator | EMRAP Managing Editor He/Him/His Instagram: @EMSwami
HOB 30 degrees not ideal for mech vent in obesity
-Pushes abdominal girth into diaphragm making diffi to deliver breath
-Data (PMID:33432600, 37832782) suggests reverse trendelenberg better position
-If can’t maintain reverse trendelenberg, consider lying flat
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#EMIMCC
Super interesting topic. I’ve done this and teach it but will have to reconsider
09.02.2026 14:35 — 👍 4 🔁 0 💬 1 📌 0
Cannabis + CV Risk
-Regular cannabis use (3x/week) linked to incr risk CAD, stroke, HTN, heart failure + possibly mortality
-Edibles carry same risk
-Regular use a non-traditional ACS risk factor: HIV, CKD, chronic alcoholism, cocaine, lupus
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#EMIMCC
Femoral Central Lines are awesome!
1) Infection rate equal to rate with IJ (subclavian are cleaner)
2) Easier to place in the awake patient
3) 0% PTX rate (IJ ~ 0.5%, Subclavian ~ 1.5%)
4) Single prep for CVL + Art line
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#EMIMCC
I use the standing algorithm
03.02.2026 14:37 — 👍 1 🔁 0 💬 1 📌 0
Incr safe apneic time increases 1st pass success + safety
-Preox w/ NIV: Incr PaO2, recruits alveoli(PMID: 38869091)
-Preox + intubate w/ Bed Up, Head Elevated(PMID: 26866753)
-Apneic O2 w/ nasal cannula at flush
-Use roc over sux(+45 sec PMID 21226882 + 20402874)
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Avoid crystalloid in hemorrhagic shock
-May incr BP but not O2 carrying
-Dilute Hgb + clotting factors
-Saline contributes to acidosis + cold fluids contribute to hypothermia which worsens clotting
Patients don’t bleed crystalloid so don’t give crystalloid
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Bicarb Pushes
-Na channel blockade on heart: TCA + diphenhydramine toxicity (narrows QRS + stabilizes patient)
-Salicylism: alkalinizes urine incr toxin excretion
-HypoNa w/ seizures or significant neurological dysfunction when hypertonic saline not available
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Thanks for sharing. Definitely interesting but I question if it would be the same in critically ill non-ventilated patients presenting with metabolic acidosis
Regardless, agree that infusion is the bigger chance for a win
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
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Agree with you but, BICARICU2 was infusion not push dose which I think matters
also, dialysis is a bit of a clinician driven thing and this wasn't blinded
regardless, the minimal cost of some bicarb compared to dialysis is a win
Can I suggest getting a cup of coffee instead?
23.01.2026 18:53 — 👍 2 🔁 0 💬 1 📌 0only if you really really really really want to
23.01.2026 18:52 — 👍 1 🔁 0 💬 0 📌 0thanks for sharing. I've got to review in full but issues I see: how was bicarb given (this seems like infusion, not push dose), obviously not an RCT (lots of confounding) and they excluded things like DKA which is odd
23.01.2026 18:51 — 👍 1 🔁 0 💬 0 📌 0
No role for bicarb pushes in metabolic acidosis
-Bicarb only incr pH if incr ventilation
-Met acidosis w/ resp alkalosis are maximally ventilating + blowing off CO2
-Intubating unlikely to help
-Bicarb pushes will worsen acidosis if not increasing ventilation
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Observation Post-Epi in Anaphylaxis
-Epi 0.5 mg IM: only critical med in anaphylaxis. If A, B or C, give E
-Biphasic rxn extremely rare: 0.18% (PMID: 24239340) + can occur days out
-I typically observe X 2 hours. Key is to ensure access to epi autoinjector
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As an TCCC instructor I would add "reassess constantly, consider conversion or removal if not needed, and be prepared to manage Reperfusion injury"
19.01.2026 15:05 — 👍 2 🔁 1 💬 0 📌 0
Tourniquet is limb/life saving if used properly
-Know where bleeding coming from? Place tourniquet 2-3"/5-6 cm proximal
-Can't tell where bleeding coming from? Put tourniquet as high up on limb as can
-Tightening: pull strap tight then wind windlass 1-2 times
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HTN not universal in aortic dissection: up to 20% hypotensive
-Hypotension can result from measuring BP in arm w/ dissection flap.
- More dangerous: pt dissected back through root + has tamponade.
Dissection + hypotension = POCUS looking for tamponade
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EVERDAC(PMID: 41159885)
-Early art line didn’t affect mortality in shock(mainly sepsis)
Reasons for early art line
-Non-invasive cuff unreliable
-Vasoconstrictive shock(trauma, cardiogenic)
-Need reliable beat to beat SBP (ICH, aortic dissection)
-Cardiac arrest
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Standard Geometry Video Laryngoscopy (SGVL) still my primary tool for intubation
-Advantages of video but is independent of tech
-If screen fails or video covered in blood/vomit, can rapidly convert to DL
-Hyperangulated VL doesn’t give you the option to go DL
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Dealing w/ a Difficult Consultant Tip #3
-Only emply when crystal clear you’ve got right consultant + consultant refuses w/o good reason
-Make it personal: “what if it was your mother/kid.”
-Appeal to higher authority (attending, chair)
-Document refusal
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Dealing w/ Diff Consultant Tip #2: Restate case + ask for alternate plan
-Often on hearing repeat presentation, consultant agrees w/ you
-On occasion, consultant says need diff consultant/transfer
-Either way, ends w/ clear path to get issue addressed
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Dealing w/ a Difficult Consultant Tip #1: Ask Why?
-Why consultant declining to see/admit pt?
-Often reveals miscommunication issue: wrong consultant, doesn’t understand emergency nature
-Asking for clarity often gets you + pt what’s needed w/o creating conflict
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Stop Indiscriminate Panscanning in Trauma
-Data: panscanning not better than standard evaluation; found to be better than no evaluation
-Downsides:Rad exposure, incedentalomas ➡️ unnecessary testing/interventions + iatrogenic harm
-Biggest downside: delays in care
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Evaluation same for syncope + near syncope
-Meta-analysis: same rate 30-day bad outcomes
-Same pathology present in both
-Don’t be less concerned if patient “almost” passed out
-Most patients can still be discharged home with f/u after negative ED workup
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updated the IBCC chapter on BRASH
added a treatment checklist that walks you through resus of a sick BRASH pt
BRASH is uncommon & there are lots of moving pieces, so the checklist is a helpful cue to provide comprehensive treatment of all the BRASH components
emcrit.org/ibcc/brash/ #EMIMCC
Say No to Needle Cric Approach
-Open technique w/ Scalpel-Finger-Bougie superior
-Crics are rare + cric kit adds unneeded complexity
-Needle cric fails in a way that is unsalvageable
-Adrenaline impedes your fine motor skills needed for needle based approaches
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Dogmalysis: pretreatment for IV contrast is ineffective in reducing the risk of serious adverse reactions and harms patients by delaying definitive diagnosis.
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D-dimer in PE: High false pos rate at standard thresholds
-Age-adjust(PMID: 24439717) + YEARS(PMID 28549662) incr threshold w/o incr miss rate
-Lancet Study(PMID: 41135553) simplifies: If PE isn’t most likely dx, double threshold
-0% miss rate w/ 19% decr CT
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