medicine of the PITT: status epilepticus in pregnancy
if you're using levetiracetam as your go-to antiseizure med (as most folks are), then the treatment is essentially the same as usual
add Mg, but Mg prevents sz recurrence (rather than lysing active sz) #1/2 #EMIMCC
Myth: Ketamine increases ICP in TBI ➡️worse outcomes
-Myth originates from low quality data
-Recent data shows ICP unchanged + CPP unchanged or slight incr
-Ketamine advantages: more HD stable + physiologically may be beneficial
-Bottom line: safe to use in TBI
youtube.com/shorts/deykT...
#EMIMCC
is there a reason that we don't use more IV glycopyrrolate for status asthmaticus?
admittedly minimal direct evidentiary support, but makes sense & indirect evidence
seems more benign than various alternative treatments (eg intubation, ECMO, extracorporeal CO2 removal). #EMIMCC
Orthostatics worthless in assessing volume status
-50% > 65 + 44% teens orthostatic at baseline(PMID 9109468, 12006955)
-Perform poorly in known volume loss(PMID 8198307)
-Useless in assessing those w/ fluid depletion from vomiting, diarrhea (PMID 10086438)
youtube.com/shorts/Dvq5R...
#EMIMCC
Surviving Sepsis 2026 is here & it's even more loony tunes than I was expecting.
They're promoting pre-hospital ABX & preemptive broad-spectrum IV antibiotics for intubated patients.
This insane fever dream is an antimicrobial stewardship nightmare.
Embarrassment for SCCM. #EMIMCC
kudos to ACEP for calling out the Surviving Sepsis Campaign 2026 guidelines and not joining in this madness.
ACEP is great at making evidence-based policies that actually *help* provide better patient care.
When ACEP is politely burning your guideline, you’re in trouble. #EMIMCC
One point that isn't mentioned here but too often forgotten when noradrenaline seemingly isn't working:
Are you actually using a representative blood pressure? Not so rare that a better (more central or better line) fixes the problem. Look at the whole patient, not just a number!
#emimcc #cccsky
Sux Contraindications
-Bumps K by ~ 0.5 mEq: Problem if ESRD/CKD + unknown K
-Exaggerated incr K in malignant hyperthermia, motor neuron disease, muscular dystrophy, GBS
-While these situations are uncommon, adds to cognitive load in high stress scenario
youtube.com/shorts/kD2IK...
#EMIMCC
Safe to give 3% hypertonic saline through a peripheral IV bit.ly/49t5GcI
Retrospective study w/ 216 administrations of 3% by PIV + only 8 minor complications
Bottom line: don’t delay 3% hypertonic administration for placement of a central line
youtube.com/shorts/M5AyB...
#EMIMCC
Kaplan-Meier plot showing the relative bleeding risk between rivaroxaban and apixaban over 90 days, clear separation and clearly higher risk from rivaroxaban
The end of the road for rivaroxaban? Shows how important direct comparative trials among drugs within the same pharmacologic class are. #emimcc #cardiosky www.nejm.org/doi/full/10....
Perhaps this might be a feasible workaround when needing a DOAC & patients are on concurrent strong CYP3A4 inhibitors/inducers (e.g. phenytoin, carbamazepine, rifampin, phenobarb, azoles...etc). Edoxaban is a P-gp substrate though!
Here's a DOAC–CYP interaction workaround. If DOAC is needed w/ CYP3A4 concerns, consider edoxaban. It’s <4% metabolized by CYP3A4 unlike apixaban, rivaroxaban & dabigatran (20-50%). Caveat..avoid if CrCl>95 mL/min...renal clearance is too efficient, reducing efficacy👇 #emimcc #medsky #hemesky #Rxsky
Steroids in Asthma Exacerbations
-Short course of steroids reduce ED revisits/admissions
-Anti-inflammatory reduce bronchial inflammation + bronchospasm
-Also upregulate beta receptors in lung incr sensitivity to inhaled beta agonists (effect kicks in in minutes)
youtube.com/shorts/PopLV...
#EMIMCC
Finally the Hyponatremia Intervention Trial is published and it is a big disappointment
pbfluids.com/2026/03/fina...
New JAMA review attempts to equate pulmonary congestion with systemic congestion ("volume overload")
This is sloppy & often wrong
Pts w/ LV failure often have pulmonary congestion w/o systemic congestion
Pts w/ RV failure usually have systemic congestion w/ dry lungs
CVP isn't PCWP
#EMIMCC
This infographic highlights the critical role of Emergency Medicine Pharmacists in cardiac arrest, trauma resuscitation, and rapid sequence intubation. It demonstrates how pharmacists improve medication safety, optimize dosing and timing, and enhance adherence to evidence-based protocols during high-acuity emergencies. Overall, it showcases the impact of pharmacists in strengthening resuscitation teams and improving patient care when seconds matter most.
For #PharmacyAwarenessMonth, I’m highlighting the role of EM pharmacists in cardiac arrest, traumas & intubations…one of many ways #pharmacists make a difference each day! Optimize #meds, ↓errors, improve lifesaving care timing. Proud to stand with dedicated pharmacists☺️💪🔥 #pharmacy #Rxsky #EMsky
Happy Pharm Awareness Month #PAM2026 to my incredible pharmacy colleagues in Canada & around the🌏! Proud to be a pharmacist alongside such dedicated colleagues. The work we do isn’t always easy but it matters...every💉💊, every💬, every🤒we help. Grateful to be in this with all of you 🙏 #pharmsky #RxSky
🔥Just published 🔥
TAPER-V RCT
In this RCT of 256, a 4-week vancomycin pulse and taper regimen *had a probability of 74% to be superior to a standard 2-week pulse regimen in patients a first episode or first recurrence of CDI
Vanco for 10d is obsolete! #IDSky #EMIMCC
jamanetwork.com/journals/jam...
Insulin bolus typically not necessary in DKA but, consider if:
Delay in getting insulin drip from pharamacy.
Severe acidosis: reach therapeutic levels faster + fix the acidosis faster
Bolus dose: 0.1 U/kg
youtube.com/shorts/pYybS...
#EMIMCC
Fresh Blog: Mythbusting the use of beta-blockers for sinus tachycardia in thyroid storm
This is one of the most dangerous & pervasive myths currently in circulation about acute care
B-bl commonly precipitate shock or even arrest in these patients...(#1/2)
blog: emcrit.org/pulmcrit/tst... #EMIMCC
There are few absolute rules in medicine but «never treat sinus tachycardia, treat the cause» has extremely few exceptions.
#emimcc #cardiosky #medsky
1/🧵what happens after stopping #glp1 agonists like #semaglutide (#Wegovy #Ozempic) or tirzepatide (#Mounjaro #Zepbound)?
Recent BMJ analysis looked at #weight regain & cardiometabolic changes after discontinuation. Let’s break it down 👇 #medsky #pharmsky #IMsky #Endosky #diet #lifestyle
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
youtube.com/shorts/QltA6...
#EMIMCC
The new 2026 AHA/ASA stroke guidelines include this table 👇 for the management of thrombolytic-induced angioedema.
There is NO discussion or any additional text about this topic.
I find this to be insufficient, not evidence-based, and potentially confusing... #1/2 #EMIMCC
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
youtube.com/shorts/gQrwA...
#EMIMCC
10/ TLDR: before stopping glp1 therapy, discuss long-term plans for weight maintenance, lifestyle support, patient expectations...
glp1 agonists are highly effective but stopping them often leads to predictable weight regain, similar to stopping meds for other chronic diseases
9/ Why does rebound occur? 🤔
- appetite suppression ends
- metabolic adaptation persists
- behavioural supports may not be sufficient alone
8/ This doesn’t mean glp1 agonists don’t work...
it just reinforces that obesity is a chronic disease, not a short-term treatment problem...
7/ It wasn’t just weight...
cardiometabolic benefits (HbA1c, BP, lipids) also gradually reversed after discontinuation, often within ~1–1.5 years!
6/ Greater initial weight loss = greater rebound!
Patients who lost the most weight on glp1 receptor agonists also tended to regain weight more quickly after stopping...