Leon Chen, DNP

if you’re really struggling to choose between two therapeutic options…

it probably doesn’t matter which one you pick 😆

a black background with a white nike swoosh on it ALT: a black background with a white nike swoosh on it

when admitting a hypothermic patient, check a TSH and random serum cortisol

don’t need a new blood draw (just add it on to the last blood draw sitting in the lab)

don’t waste a ton of neurons on this, just check it like a reflex arc.

in ~1/50 cases you’ll look like a diagnostic genius 🤣 #EMIMCC

Common things are common. An uncommon presentation of a common disease is still more common than an uncommon disease.

Also decreases any animosity between the two groups

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

#MedSky #EMIMCC

bit.ly/41JI8jt

YouTube video by EMSwami Andexanet Alfa Is Just Expensive Garbage #emergencymedicine #resuscitation #criticalcare

Kudos to @fda.gov for rejecting full approval of andexanet alfa

ANNEXA-1: Andexanet alfa w/ a strong signal for HARM compared to usual care in patients on a DOAC w/ ICH w/ no evidence of clinical benefit

#MedSky #EMIMCC
youtube.com/shorts/EOqzP...

Good example of rule of threes. RVOT, aortic root and left atrium should look about the same diameter in PLAX, here one is too big #pocus

Published in JAMA Surgery, part of the JAMA Network of journals

A lot of parainfluenza. No flu yet.

EM has been arguing this point for a long time

@sccmcriticalcare.bsky.social @neurocritical.bsky.social @neurocritcarej.bsky.social @criticalcarereviews.com @atscommunity.bsky.social @americanheart.bsky.social is a good list to start!

People will inevitably tell you that their favorite inodilator (usually milrinone) is better since there are fewer arrhythmias compared to the other (usually dobut)

DOREMI says 🤷‍♂️ #emimcc

ICU Stories:

Middle-aged patient w multiple co-morbidities (CAD/DM2/strokes/seizures/peripheral vasc dz/atrial fibrillation/chronic Foley - UTIs etc) was sent from nursing home to the ED for evaluation of fever/ hypotension. Urine was purulent. CT showed hydronephrosis & bladder wall thickening:

ICU Stories:

Patient with COPD-obstr sleep apnea (5 l/m O2 nasal cannula at baseline) / A. fib / diastolic heart failure / DM2 / vascular dz / HTN / CKD / morbid obesity (BMI 50) etc presents to the ED with dyspnea/cough/weakness x 2 days. Felt warm; did not check temperature. CXR in ED:

Effect of Noninvasive Positive Pressure Ventilation on the Need for Endotracheal Intubation in COPD This randomized clinical trial compares the effect of high-intensity noninvasive positive pressure ventilation (NPPV) vs low-intensity NPPV on the need for endotracheal intubation in patients with an ...

The HAPPEN trial
Go hard or go home because high intensity NIPPV (10-15ml/kg IBW TVs) vs low intensity (6-10) in COPD exacerbations reduced the rate of patients meeting predefined criteria for intubation by 9% (ARR).

jamanetwork.com/journals/jam...

important thread 👇

{norepi + vaso} can often induce a state of *normotensive* vasoconstrictive shock

this is why I dislike blind algorithms that start with NE, then pile on vaso on without considering global hemodynamics

for experts, there is no such thing as a “1st/2nd/3rd line” pressor #EMIMCC

Severely dilated cardiomyopathy d/t cocaine use disorder. EF 5%.
#POCUS

Critical Care Management of Acute Venous Thromboembolism: Integrating Pharmacotherapy, Thrombectomy, and Temporary Mechanical Support Venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis, carries significant morbidity and mortality risks, and is conventionally managed with

'Critical Care Management of Acute Venous Thromboembolism: Integrating Pharmacotherapy, Thrombectomy, and Temporary Mechanical Support'
#tnkase #thrombectomy #FlowTriever #ecmo #PE #vte #dvt pulmonary embolism #pulmSky #emimcc
www.uscjournal.com/articles/cri...

YouTube video by Anand Swaminathan ECG in Seizure

Differentiating Syncope vs Seizure:
- LOC + loss of postural tone in both
- GTC movements often seen in syncope
- Tongue biting + incontinence can be seen in both as well

Post-ictal period is key. Brief confusion post-syncope but post-ictal = seizure

#MedSky #EMIMCC

youtube.com/shorts/5_zu_...

Oh of course I’d also talk to the pt if they’re able to participate.

Look for existing documentation on goals of care. If pt can wait, I’d explore “everything done” with fam. If no documentation going against intubation and family understands what it entails, I’d intubate.

New paper just dropped in @jama.com showing the miracle that are HPV vaccines

Full article here: jamanetwork.com/journals/jam...

TL;DR version of article: Get your kids vaccinated (both boys and girls) because it prevents cancer

Restrictive Cardiomyopathy
- Normal systolic fx
- Small LV chamber size
- Granular myocardium
- Mild atrial enlargement

Eyeballing severity of MR. Best done in PLAX view. Measure the vena contracta (narrowest portion of jet at the mitral valve).
- Mild MR: < 0.3 cm
- Moderate MR: 0.3–0.69 cm
- Severe MR: ≥ 0.7 cm

#POCUS

One of the hardest skills to master as a #POCUS trainer is supporting learners to optimise their views without grabbing the probe.

The ability to understand how to manouvre someone else’s views is POCUS-Jedi level skills.

@katiewiskar.bsky.social does it here in a great skeetorial.

#emimcc

VExUS: common misconceptions, clinical use and future directions - The Ultrasound Journal There has been a significant interest in venous congestion in recent years, among which the VExUS score has been prominent, both in clinical practice and research efforts. We have noted some recurrent...

'we review the physiological basis of the VExUS assessment as a measure and marker of venous congestion from the organs’ standpoint and its role as part of the emerging concept of fluid tolerance' #pocus #pocusky #emimcc #cardiosky #vexus
theultrasoundjournal.springeropen.com/articles/10....

A lot of it is insecurity no? The need to justify its existence.

Choose 20 books that have stayed with you or influenced you. One book per day for 20 days, in no particular order. No explanations, no reviews, just covers.
#Books
#BookSky
💙📚
#BookChallenge
2/20