Simone Gherardi

#FOAMed if you want to know how medicine will be practiced #EMIMCC

+ be aware of undifferentiated shock in extremis (cardiac arrest in seconds) of every morbid condition

B.D.G.O = Bad Decision Good outcome. Pericolosissimo e sconosciuto

first:

combination inhaled epo + nitric simultaneously (I know its expensive, put it on my tab)

epi gtt for MAP > 85

to improve cardiovascular reserve if the clot flies off

then:

50 mg tPA

(very little data on IR for clot in transit)

Great! First glance: add position somewhere (still see patient lying flat)+ I'm unsure if flumazenil deserve any mention. To me the risk is to give any cognitive energy to something which tend to complicate the steps while you need to keep it simple at that point and focus energy on what matters

@pulmcrit.bsky.social hot take on RSI trial. Again, more questions than answers. But this editorial is amazing and gives you a different view on the trial amongst many other you're about to read in these days. #EMIMCC #FOAMed

No difference in mortality and such a big gap in CV outcome (surrogates). Something unmesured? #EMIMCC

article: https://pubmed.ncbi.nlm.nih.gov/37377263/ IBCC chapter about acute liver failure: https://emcrit.org/ibcc/alf/

updated the acute liver failure chapter

biggest change is increasing support for early CRRT to remove NH3 (to reduce elevated intracranial pressure)

now rec'd for clinically overt encephalopathy (Grade 2-4)

if admitting to ICU for ALF & encephalopathy, just dialyze

emcrit.org/ibcc/alf/ #EMIMCC

Not so fast with the capillary refill guided resuscitation (ANDROMEDA-SHOCK-2) As far as I can tell, despite talking about the paper widely at conferences, I never included a write up of the original ANDROMEDA-SHOCK trial on First10EM. (Hernández 2019) (There is a massive file of all the topics I want to cover, and would cover if this was a job rather than a hobby. I assume it just got lost in there.) As a reminder, that trial showed that clinical management of septic shock patients based on capillary refill time was not statistically different from management guided by trending lactates, although there was some optimism because the point estimate for all cause mortality was actually 9% better.

Not so fast with the capillary refill guided resuscitation (ANDROMEDA-SHOCK-2) #FOAMed

kermit the frog is wearing a black hoodie and kermit the frog is wearing a black hood . ALT: kermit the frog is wearing a black hoodie and kermit the frog is wearing a black hood .

PPS - Bottom line is that if your critically unwell patient needs a CT scan you should just get the scan

- Contrast-induced nephropathy is a myth emcrit.org/ibcc/contrast/

- Contrast allergy now just requires a dose of antihistamine

- Radiation risks are minimal (especially for older adults)

Sooo good

Already listened to the episode (emcritter here) and I agree. But as it is never a "solo" parameter evaluation, I was wandering if there was another reason to exclude PP, which in some circumstances could be helpfull

DBP and pulse pressure are somewhat redundant. I added pulse pressure but they will generally trend in opposite directions provided the MAP is held in a somewhat fixed position around 70mm

I guess the evaluation of congestion is kinda assumed... also I wanted to de-emphasize the whole fluids thing

Why didn't you put in the algorhytm pulse pressure (>40) which was a checkpoint in AS-2?

2) in the rest of the chapter I have not seen a section about fluid tolerance (paired with fluid responsiveness which is present)..is there a reason?

One more time thank you for the IBCC, is a thing of beauty

Faith, Evidence and the Stars The most up-to-date critical care website in the world.

"CRT, like a star, is not the destination but a guide for the journey". AS-2 it's not just a trial, it's a manifesto, an act of faith #EMIMCC #Andromeda #AndromedaShock2 #Sepsis
criticalcarereviews.com/blog/current

ICU Snapshots:

Young patient with multiple medical problems presented to ED for evaluation of "weakness". Decompensated; had to be intubated & placed on pressors (norepinephrine) before being transferred to our ICU

BP control can be achieved w sympatholysis and sedation + positive pressure ventilation. I don't see the urgency of put in the mix any antihypertensive med before intubation and I think it's a very dangerous move. If BP high after tubing lets add some drugs. But come on...is not an aortic rupture

PulmCrit - 2025 AHA & ESICM guidelines on post-arrest care The ESICM and AHA both just released new guidelines on post-arrest care. It's always interesting when two professionals produce "evidence-based"

emcrit.org/pulmcrit/202... #EMIMCC Some @pulmcrit.bsky.social 's highlights about aha vs erc cardiac arrest guidelines #Emcritters

The 2025 European Resuscitation Council Guidelines have been released

All 11 plus the executive summary included below

CCR Journal Watch
https://criticalcarereviews.com/latest-evidence/journal-watch

but not in a hurry😉

PLS SHARE. FOR PATIENTS SAFETY SAKE
#EMIMCC
www.tandfonline.com/doi/10.1080/...

ICU Practice - Return to Basics:

When you prepare for the "average" intubation (no cardiac arrest, no active emesis), how do you pre-oxygenate the patient?

Oxygen mask/nasal cannula?
Non-invasive ventilation?

ED PHEM doc here. I'm using more and more NIV for preox (usually NIV-ST on Hamilton T1). So I'm giving back up breaths on peep during apneic phase. #EMIMCC

Give diuretics as boluses
look at Chloride, k+ and pH
Multimodal diuresis
Not every form of "heart failure" need diuretics in the firsts hours
#EMIMCC
#DiuresisJedi
#Deresuscitation

4. Probably it s better not to try anything "softer" than intubation. But while preoxygenating I d put him on 10 cmh20 of peep at least

Anyone with similar cases? how did it happen? Just a lack of proper follow up? Some syndromic presentation? It left me kind of unconfortable #EMIMCC is incredibile #FOAMed

Had a case of elderly M with bilateral carotid stent intubated for sudden collapse and coma. CTA + CTP showed bilateral stent occlusion and complete shut down of anterior brain circulation. Signs of right upper limb ischemia (cold, pulseless). #EMIMCC #FOAMed #Stroke

A case in which V Tach should be prevented with adrenaline and chronotropism #EMIMCC

AHAHAHAHAHAHAHA

@gx8a.bsky.social tu, midazolam team 🤢