Clay Josephy

First thought: neuro twaves. But sounds like i was wrong…darn it.

what Swami is referring to here is a “bolus” but given as a slow infusion over a period of time. Theres RCT evidence that says it reduces psychomimetic rxns versus pushing it over a few minutes

Interesting question and context. In the ED i tend to give a bolus then start a drip. In the ICU i just start the drip. No particular reason, you just made me self reflect 🤷🏻‍♂️

Important to be clear what “infusion” means bc even giving a single dose of 0.3 should be done over 15-20 mins to reduce SE

Oh buddy!
This job is just a maze of booby traps. Crazy

ICU Stories:

Elderly patient with multiple medical problems (HFpEF / A fib / HTN / PE / obesity etc) was admitted w CHF exacerbation. Improved w diuresis but developed left upper extremity edema; diagnosed with extensive DVT for which Interventional Radiology (IR) was consulted

I love this. I see this from time to time with a bariety of triggers. Maybe an HLH spectrum phenomenon. Super interesting. Ive had some luck with Methylene blue or B12 on a couple occasions.

Awesome stuff. Loads of great info here. Thanks!

ICU #POCUS:

This is a recently published, information-dense document. It may be a bit technical for the average POCUS user but if you manage patients who harbor a right heart (😊), consider reading it:

Im just gonna leave a little chuckle here bc this is so true and so common 🤣

This cannot be over emphasized. If you just titrate this slowly to your goal it takes forever.

Dude totally agree. I wqs a little tachycardic during that scene. ive seen this twice now. This is not the EPi and high fives scenario. This is put the tube in and wait it out. This goes badly fast.

I like this. At least by ultrasound. You can get away with using inotropes +\- diuretics but honestly if things dont turn around real quick (lactate, UOP, etc) i strongly believe you need some data. Whether thats pocus or PAC or even Ficks w an ScV02 whatever. I agree with you here.

Agree wholeheartedly 💪🏼

YouTube video by Peter Johns Syndromic vs diagnosis based approach to dizziness/vertigo: Which is better?

Great video from Dr Peter Johns detailing the syndromic vs diagnosis based approaches to vertigo in the ED #emimcc

youtu.be/e9Qcuzi3m6Q?...

💯%
Lots of em😂

A quick #VEXUS thread 🧵-

3 reasons why the portal vein is the most useful single venous doppler waveform 🥇

(if you're only going to do ONE site to look for venous congestion, this is probably the most useful one!)

#emimcc

Well. I think i hear ya.
But Flu = CAP. Many (most?) CAP is viral, flu is a common pathogen.

So youre saying lobar consolidations, elevated procal etc youre using steroids, but diffuse GGOs, lower procal, but still sick, no.

Thats reasonable honestly, just seems like a lot of overlap.

Very rational. I mean, theres quite a few observational studies that are consistent, despite the fact that none are controlled. Not exactly cause and effect type science but consistent observations in various settings strengthens a hypothesis, right?

Oh boy 🤦🏻‍♂️

So not up front huh? Just when things are getting worse despite standard treatments? Reasonable.

Right? I mean pooled data on very heterogenous groups of lung injury seem to benefit and until theres some prospective data or at least a tested mechanistic hypothesis (?innate immunity to recurring exposure to seasonal flu?) as to why its different I cant imagine it would be exempt 🤷🏻‍♂️

#foamed #foamcc #meded #medsky #idsky #emimcc #cccsky @imcrit.bsky.social @pulmcrit.bsky.social @nickmark.bsky.social @emcrit.bsky.social @zentensivist.bsky.social

homer simpson is standing in a grassy field ALT: homer simpson is standing in a grassy field

So during this bad flu year with the many people we are putting on IMV and even VVECMO, knowing that theres no updated evidence for FLU+ patients specifically….

Are we using steroids for severe CAP or ARDS in FLU+ patients?

Disclosure: I have been 🤫 🤐

IDSA/ATS still recommends against steroids in FLU+ patients.

CAPECOD excluded FLU+ pts.

Yet many severe CAP and ARDS are caused by FLU and a non trivial number of them are c/b bacterial PNA.

Ok team. Rubber meets the road
Its a bad flu year so we have to talk about it.
We have CAPE COD trial, and updated guidelines for steroids in CAP, and a shift toward erring on the side of using steroids for CAP and ARDS

Traditionally based on observational data alone steroids not rec’d in FLU+ CAP

a cardboard box that says box of shame ALT: a cardboard box that says box of shame

Ah come on. Ive never done that! 😂

I use it a lot. Anecdotally it seems to be less sedating and probe to side effects than the antihistamine/anticholinergic versions of “msk relaxers”

I use to use it routinely in trauma pts and msk related pain but i dont see those pts much these days

Cool review. Good on the authors. I was hoping they would delve into the catheter based therapies evidence or lack thereof (the big black box) but i did think it was cool they brought up VAECMO. Good stuff.

Wow. Ibutilide. What a concept. Ive never given it. Good point though about aaF in the ICU vs ED. Different disease practically. Its kind of fun in the ED, kind of a bane in the ICU. Thx for the recommendation ill have to look further into that.

Another scenario may be when you have VAECMO and an impella in, your PAC estimates of CI are kind of unreliable so was wondering if VTI + flows from MCS devices may be the way. Gets tricky ya know.