I’m a little skeptical that antibiotics do a whole heck of a lot for sinusitis at all 🤷‍♂️

the latest Cochrane review says maybe it accelerates recovery but it’s not like people are dying from untreated sinusitis

Comparison of 8.4% Sodium Bicarbonate vs. 3% Sodium Chloride in Severe Hyponatremia: A Retrospective Cohort Study - PubMed This study found that a single 50 mL dose of HTB more often resulted in obtainment of guideline-recommended post-intervention serum sodium goal concentrations than a 100 mL HTS dose. Additional studies...

Cool study - an amp of sodium bicarbonate (50 ml 8.4%) raises sodium similar to a boils of 3% - as expected of course!

pubmed.ncbi.nlm.nih.gov/41937305/

@pulmcrit.bsky.social @kidneyboy.bsky.social

#nephsky #emimcc

tough to say but yeah, there may be an expanded role here for keeping pts, supporting temporarily with pulmonary vasodilators and using variable dosing strategies for tPA

reminds me of the time before we had catheter-directed embolectomy

used more tPA & overall our outcomes were probably similar 😆

a little girl wearing sunglasses is standing in a doorway and says `` good luck ! love you you got this gogg ! '' ALT: a little girl wearing sunglasses is standing in a doorway and says `` good luck ! love you you got this gogg ! ''

avoid truly fetotoxic meds (e.g., valproic acid), but these are uncommon

mostly focus on providing excellent & usual care (doing the basics well)

IBCC chapter on status epilepticus: emcrit.org/ibcc/sz/#top

IBCC section on status in pregnancy: emcrit.org/ibcc/ob/#sei...

a man with a stethoscope around his neck is sitting in front of a sign that says " only time will tell " ALT: a man with a stethoscope around his neck is sitting in front of a sign that says " only time will tell "

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

PS- updated the critical asthma chapter

tough to write (opinions >>> data)

I've boiled it down & made it more prescriptive (cannot cover every treatment style/option)

lotta ways to skin the asthma cat, this is my general preference, adapt to the patient in front of you

emcrit.org/ibcc/asthma/

You're basically correct, but there are some exceptions, so 99% figure may be too high.

[1] Some patients don't respond to lysis (old rubbery clot)

[2] There is a group of high-risk submassives at risk of ICH who benefit from catheter thrombectomy. Likely smaller than we used to think, maybe ~5%.

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

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It's wild that a single company managed to brainwash the entire specialty of neurocritical care into believing that NPi is the be-all and end-all of pupillometry.

It's not.

eg: for predicting DCI after SAH, trending CV is better 👇

More on NPi: emcrit.org/pulmcrit/npi/

Pet peeve: Research on pupillometry that only reports the neural pupil index (NPi) is worthless & will wind up in the ash heap of history.

NPi is *proprietary* & calculated with a *secret* formula by *one* company's product.

Does this seem like ideal scientific practice?...#1/2 #EMIMCC

meh, these things come and go… i’m hoping everyone will forget about it soon

Analgesia and sedation for the critically ill patient CONTENTS [1/5] pure analgesics Acetaminophen Ketamine, pain-dose ➡️ Methocarbamol Lidocaine ➡️ NSAIDs:  Celecoxib  Diclofenac  Ibuprofen  Indomethacin  Ketorolac  Meloxicam  Naproxen [2/5] analgosedat...

source:

emcrit.org/ibcc/pain/#top

here is a discussion of nalbuphine:

emcrit.org/pulmcrit/nal...

note to self: use more IV nalbuphine

it's supported by robust theoretical & clinical evidence

I'm pretty sure the only reason we don't use it more often is due to our training and habits (habit-based practice, not evidence-based practice)

esp. useful in patients with tenuous respiratory drive

PS - Due to some feedback on X and Bluesky, I updated the section on functional endpoints to clarify my thoughts on this. This is admittedly murky and not the primary reason to perform thrombolysis.

Vibby Vibby Vibes GIF ALT: Vibby Vibby Vibes GIF

HI-PEITHO #2/2:

🔊 Select pts benefit (intermediate-high risk, borderline vitals, RV/LV >1)

🔊 Study used a fancy vibrational catheter that delivered tPA directly into the pulmonary artery, which is almost certainly unnecessary & adds procedural risks.

blog: emcrit.org/pulmcrit/hip...

Fresh blog on the HI-PEITHO trial 😁

🔊 ~18 mg alteplase over 7 hrs is safe (no ICH, no difference in bleeding rates)

🔊 Alteplase reduces the risk of cardiopulmonary decompensation and poor functional outcomes

#1/2 #EMIMCC

will blog about this soon.

It's a very useful trial once you realize that the catheter delivery of tPA is equivalent to peripheral tPA.

Unfortunately, most people won't realize that.

Industry sponsors are trying to hijack the entire research agenda and are largely getting away with it.

it's hilarious watching people desperately try to apply the AHA/ACC risk stratification system to the HI-PEITHO trial

HI-PEITHO was built off of the ESC risk-stratification system and it's impossible to map these patients onto the AHA/ACC classification.

ESC is better. just use it.

missing sepsis - bad

misdiagnosing another catastrophe as “sepsis” - also bad

it almost makes me think that maybe we should specially train people how to identify and differentiate these disease processes and provide personalized care 🤔

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

Yeah, I’m not sure who they’re trying to help but surely not us.

Other organizations (eg ACEP) do a much better of creating practice guidelines that don’t box doctors into a medicolegal corner for trying to do the right thing.

a bald man is sitting at a desk giving a peace sign with his hands . ALT: a bald man is sitting at a desk giving a peace sign with his hands .

They're air-quoting themselves in their own guideline.

The whole thing is bizarre.

PulmCrit: The surviving sepsis campaign 1-hour bundle is... back? The surviving sepsis campaign (SSC) has had substantial problems dating back to its inception.  The original backbone of the guidelines was a

PS - I'm not going to do a blog on this because I've already done a lot of blogs on the SCC and they don't work.

The SCC is just too much of a behemoth to resist.

If you're looking for a PulmCrit blog on this theme, this one from 2019 is still good.

emcrit.org/pulmcrit/ssc...

sick patient in the ambulance, and there's a red light at the intersection?

VANC ZOSYN

It just doesn't make any sense.

We spend tons of effort checking procalcitonin and stopping ABX as soon as possible, then the SCCM is just like "hey what if we gave broad-spectrum antibiotics to everyone".

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

target sat >88%

pacer set to 88 b/m

LFG

a little boy is driving a red toy car down the street . ALT: a little boy is driving a red toy car down the street .

when your post-CABG patient is in shock with a heart rate of 55 and you start pacing through the atrial wire at 88 b/m

sorry, drowning pancreatitis patients is the worst