ACEP 2018 (PMID: 30732981) “literature does not support a significant assoc between fasting length + incidents of adverse events in adult/pediatric patients. Urgency of procedure dictates necessity of providing sedation without delay regardless of fasting status.”
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#EMIMCC
No Role Loop Diuretics in SCAPE Resus
-First 10 min: focus on NIV + High-dose NTG
-< 50% of patients w/ volume overload (PMID: 21934091, 21934091) + many w/ volume overload have ESRD
-After stabilization, assess volume status (IVC, JVD, edema) + dose accordingly
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#EMIMCC
WPW: Avoid ABCD drugs (adenosine/amio, beta blockers, CCBs + dig)
- Why? Blocking the AV node pushes all conduction down the accessory pathway + can worsen tachydysrhythmias (like AF w/ WPW)
- Safest drug? Electricity (procainamide also ok but takes too long)
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#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
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#EMIMCC
Should CRAO be treated w/ lytics? NEJM PMID: 41604638
-RDCT 78 patients (40 TNK, 38 ASA)
-No difference in vision recovery (20% vs 24%)
-Increased harm in TNK including 1 death from ICH
Bottom Line: Based on high-quality data, CRAO shouldn't be treated w/ lytics
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#EMIMCC
The Data is In
Terren R. Trott, MD (@tsquaredmd) from ResusX:2025:
Multiple RCTs and meta-analyses show a selective cath strategy is just as effective as immediate intervention for post-arrest patients. High-quality ICU care is the real priority. Comment to discuss.
Age-adjusted d-dimer in DVT (PMID: 41490105)
-3200 patients in 4 countries
-700 pts w/ d-dimer < age-adjusted: 2 w/ DVT at 3 month f/u (both w/ dimer < 500)
-Using age-adjusted d-dimer incr pts w/ a negative test obviating w/o significantly increasing missed DVTs
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#EMIMCC
Suction Assisted Laryngoscopy for Airway Decontamination (SALAD) solves the soiled airway
1)Overhand grip of suction catheter
2)Lead w/ suction catheter to keep your light source/camera clear
3)Move your suction catheter to left of laryngoscope + pin in place
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#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)
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#EMIMCC
Polymorphic VT: Torsades vs Generic
-Torsades is polymorph VT w/ long QTc
Tx: electrical cardioversion (or defib if machine can’t sync) + Mg load
-Generic: almost always due to cardiac ischemia
Tx: Electrical cardioversion if unstable + often will need cath
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#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
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
Standard Geometry Blade Laryngoscope Grip Tips:
1) Grasp near blade to improve mechanical advantage
2) “3 finger” grip to facilitate gentle blade placement and serial advancement
3) “5 finger” grip once blade tip in vallecula + ready to lift
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#EMIMCC
AP pad placement superior to AL in defibrillation
-Goal w/ defib is to deliver current to as many myocytes as possible
-Large part of LV is posterior and not covered by AL pads
-AP results in higher defib success rate
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#EMIMCC
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
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#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
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#EMIMCC
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)
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#EMIMCC
Patient with pulmonary embolism develops mild hemoptysis:
- Dont panic
- Dont stop anticoagulation
- Dont give TXA
- Just continue anticoagulation
Hemoptysis is an accepted symptom of PE. It’s usually due to mild capillary necrosis & not severe (not arterial).
Hypercarbic Resp Fx results from hypovent + CO2 accumulation
-BPAP ideal NIV modality
-In BPAP, need to set EPAP + IPAP
-Larger gap between two = larger TV resulting in blowing off more CO2
-Titrate from 10/5 to 15/5 to 20/5; increase gap, increase ventilation
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#EMIMCC
Is it vasospasm?
Clinical Pearl: The most important tool in the Neuro ICU isn't the TCD or the CTA—it's the hourly neuro exam. Vasospasm management is a 21-day art form. What’s your "must-check" at the bedside?
Comment to discuss.
Post-Intubation Hypotension in Status Epilepticus
-BP often drops w/ propofol post-intubation
-Avoid turning down propofol: likely seizures will restart
-Instead, add vasopressor: hypotension secondary to vasodilation/decr cardiac contractility
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#EMIMCC
Knee dislocations: high risk for popliteal injuries which can be limb threatening
-Obtain ABIs. If ABI less than 1.0 proceed to CTA
-Skip right to CTA if high suspicion (ie weak pulse)
-Be cautious of the spontaneous reduction prior to presentation
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#EMIMCC
The use of steroids in septic shock has been debated for decades, but more recent data increasingly supports their benefit (PMID: 38250247), particularly for patients in refractory vasopressor shock.
AVAPS - ensures pt gets a set volume
-Set EPAP + 2 X IPAP (low + high)
-Machine will vary IPAP to ensure delivery of volume
-My approach: start w/ BPAP. If pt not improving or tolerating, switch to AVAPS + discuss w/ resp therapy
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#EMIMCC
Persistent juvenile T waves often mistaken for ischemic T waves
Typical features:
-Asymmetric
-Less than 3 mm in depth
-Seen in V1-3. Unusual in V4-6
Concerning differential to consider: anterior ischemia, Brugada, PE, ARVC, RVH w/ strain, RBBB (or incomplete)
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#EMIMCC
Routine Tn Not Indicated in Syncope
-LOC w/ spont return baseline w/ ACS extremely rare
-PMID: 41201260- Tn w/ poor sens/spec for predicting 30d adverse events(death, dysrhythmia, ACS, PE)
-ECG only routine test. Every other test depends on clinical evaluation
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#EMIMCC
Pulse Oximeter is THE Best Tool in Resuscitation
1)Gives you O2 sat
2)Gives you HR
3)Gives you marker of peripheral perfusion: poor waveform = poor perfusion = give volume or vasoactives
4)(May) give you perfusion index: quantifiable strength of perfusion
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#EMIMCC
NTG in SCAPE
-Priorities in SCAPE: Lysis of sympathetic response, pre/afterload reduction
-Aggressive NTG key intervention
-Large bolus: 1-2 mg q3-5 min (PMID: 34215472, 38050078, 17509731)
-Moderate bolus + gtt: 500 - 1000 mcg + gtt @500 mcg/min
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#EMIMCC
Humeral IOs are fantastic bridges in patients who are peripherally clamped down.
Pearls: Internally rotate the arm to get better access to the humeral head. After placement, avoid external rotation as it results in bending the IO or dislodgment
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#EMIMCC
Re-Ox w/ Supraglottic Device
-Standard re-ox approach is to use a facemask + BVM
-Problem is that holding a proper mask seal is a skill that can easily degrade under stress
-Solution: re-ox w/ your supraglottic device: no need to hold mask seal + faster re-ox
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#EMIMCC
