Author of the Internet Book of Critical Care ๐๏ธ Board certified in critical care, pulmonology, and neurocritical care ๐ค Zentensivist ๐งโโ๏ธ No COI ๐ฐ
University of Vermont ๐
- Tweets 14,227
- Following 534
- Followers 65,018
- Likes 19,261
approach by specialty:
neuro: tPA
cards: PCI
GI: golytely
pulm: bronch
neph: furosemide
hospitalist: IV fluid
ID: rec consult surg
surg: rec consult IR
IR: inari flowtriever
urology: tamsulosin
neurosurg: mannitol
anes: mcgill forcepts
EM: ketamine
derm: steroid
obgyn: c-section
152
530
2,208
evidence-based medicine versus hospital culture nitter.app/InterestingsAsF/statusโฆ
34
391
2,250
Dan Toomey
Flight Attendant: is there a doc on board?
Me: um, I guess I'm a doc?
Flight Attendant: Fabulous, we're saved!
Me: HELP I NEED A NURSE, RESPIRATORY THERAPIST, AND PHARMACIST STAT!
(team assembles, saves patient, I do little)
Me: that was exhausting, I need more coffee.
18
209
2,091
O.A.G
using a benzodiazepine to treat delirium-induced agitation nitter.app/ohshidt/status/1541404โฆ
29
306
1,406
once in med school i was on a rotation with one other guy.
we didn't know what to wear, so we agreed to show up in scrubs.
the next day I roll in wearing scrubs & sneakers, and he's decked out with a shirt, tie, and dress pants like the king of Italy.
med school was so weird.
one time in med school I had a classmate actually get mad at me because I said I was interested in applying into anesthesia and they said that they were applying into anesthesia and that I couldn't just blindside them like that
10
55
1,208
205,460
Trump's latest bout of gaslighting scientists has pushed the NEJM editors to explicitly recommend leadership change. unprecedented but appropriate. #BidenHarris2020
12
365
1,069
the new Surviving Sepsis 2021 guidelines are out! These are terrific guidelines for anyone who knows absolutely nothing about treating sepsis. For example, if @DGlaucomflecken actually needed to run an ICU, this would be perfect.๐๐
link.springer.com/article/10โฆ
24
281
1,148
if youโre working the ICU today like me, youโre officially allowed to use whatever antibiotics you want.
sunday AND christmas. nobody is paying attention.
interested in what happens when you combine linezolid, tigecycline, ceftaroline, and isavuconazonium? GO for it.
67
72
1,012
429,375
PIPERACILLIN-TAZOBACTAM IS NOT NEPHROTOXIC: exploring the arc of a myth over time
this was clearly a myth in 2016:
emcrit.org/pulmcrit/piperaciโฆ
blog from 2022 exploring the evolution of this myth: emcrit.org/pulmcrit/myth-pipโฆ
fresh RCT to finally settle this:
jamanetwork.com/journals/jamโฆ
18
328
1,056
242,589
I SAW IT GO THROUGH THE CORDS
โจ ๐ข๐ณ๐ณ๐ถ๐ฐ๐ถ๐ฎ๐น ๐๐ผ๐๐ฟ๐ฐ๐ฒ๐ ๐ต๐ฎ๐๐ฒ ๐ฑ๐ฒ๐๐ฒ๐ฟ๐บ๐ถ๐ป๐ฒ๐ฑ ๐ฑ๐ถ๐ณ๐ณ๐ฒ๐ฟ๐ฒ๐ป๐๐น๐
18
98
885
so it turns out that 1 family member at the bedside is roughly equivalent to 0.8 mcg/kg/hr dexmedetomidine.
19
125
887
THEREโS NO SUCH THING AS A โBETA-LACTAM ALLERGYโ OR A โCEPHALOSPORIN ALLERGY.โ CROSS-ALLERGIC REACTIONS ARE LIMITED TO DRUGS WITH EXTREMELY SIMILAR R-SIDE CHAINS. SO YOU CAN ALMOST ALWAYS FIND A SAFE BETA-LACTAM. IF YOU JUST HAVE A WEE BIT OF COURAGE, THAT IS.
ALT for more info see https://emcrit.org/ibcc/penicillin/
13
104
853
working with respiratory therapists & anesthesia to troubleshoot helmet CPAP. surprisingly comfortable. #ThisIsTheWay
66
153
877
albumin-corrected calcium level is *less* accurate than the uncorrected total calcium level ๐คฏ
I think we all know that that albumin-corrected calcium is junky and you need an iCal to really know the biologically active calcium level... but I didn't realize how bad it is ๐ฌ
21
220
901
143,581
pulse oximeters were optimized for white people, causing them to underperform in Black people - thatโs systemic racism. itโs deeply disturbing that this remains a source of confusion within a journal claiming to be โthe worldโs leading medical journal.โ
15
217
815
LR doesnโt cause hyperkalemia.
Please help abolish this myth.
Also, Iโm sorry if you spent 0.5 million on a medical education full of aphysiologic bollocks.
emcrit.org/pulmcrit/myth-busโฆ
17
263
854
if youโre ever thinking โmaybe this patient has uremic encephalopathy?โโฆ๐ง
your next thought should be: โare they on any renally cleared meds that cause delirium?โ๐
โโ๏ธ
iโm lookin at you, gabapentin and baclofen ๐ you know what you did ๐
13
103
829
11 reasons the fresh NEJM paper on remdesivir is some hot garbage
(blog: bit.ly/3b2sQcv)
33
285
822
Martin Tobin explains the physiology of asphyxiation in brutal and convincing detail. Tobin testifies that *anyone* subjected to this would have died due to asphyxiation. (Tobin is one of the most renowned pulmonologists in the world.)
9
235
791
PSA: ๐ข the mRNA vaccine is 95% effective (amazing!!). it will be given to *millions* of people, so we *will* be hearing about many vaccine failures (5% x millions). anyone who doesn't understand percentages is welcome to repeat elementary school, via zoom. that will be all.
10
203
762
FEV1/FVC is within normal limits and DLCO is preserved, but there is a reduction in FVC, TLC, and especially expiratory reserve volume. recommend clinical correlation. nitter.app/Drakayris/status/17876โฆ
19
103
769
110,641
first meaningful RCT on hydroxychloroquine
- no effect on viral clearance (despite huge doses)
- no effect on symptomatic improvement
- increased side effects
- for now, use of hydroxychloroquine should probably be limited to RCTs
(blog bit.ly/2yf10LF)
27
421
768
this is why patients with gram neg sepsis often fall apart a few hours after getting antibiotics. bugs explode, spilling LPS.
everyone: the patient is crumping, we need to add vanco
zentensivist: theyโre crumping *because* your antibiotic is hitting the bug. try steroid ๐
If youโve ever wondered what happens when penicillins kill bacteria...
they EXPLODE ๐คฏ
#MedTwitter
19
189
747
To avoid renal failure, itโs essential to avoid IV contrast CT scans and piperacillin-tazobactam. If you do need a contrasted CT scan, consider starting dialysis right afterwards to remove the contrast. Replacing piptazo with high-dose cefepime improves neurologic outcomes too.๐
55
65
741
216,967
President Biden signs an executive order banning press releases of unpublished trials, stating โEnough of this malarky, if itโs that urgent then just post the data on medRxiv, thatโs the dealโ
21
113
705
time for a fluid & electrolyte tweetorial ๐
an asymptomatic adult human presents with these findings...
18
174
750
status epilepticus: ๐๏ธ points
- don't under-dose your benzodiazepine
- ketamine is an enormously under-appreciated anti-epileptic
- neuronal damage can occur after >30 min, so target neurolytic intubation @ 20 min if refractory
(fresh IBCC chapter: bit.ly/2UD3yw2)
20
330
764
Stop making fun of older kids who still believe in Santa Claus, there are grown nephrologists who still think LR is contraindicated in hyperkalemia.
20
105
678
๐ thanks to all the pharmacists out there quietly saving lives.
ncbi.nlm.nih.gov/pubmed/3113โฆ
13
259
686
every year I accept dozens of patients in transfer for possible dialysis, when all they truly needed was pH-guided resuscitation. a better understanding about how to resuscitate the acidemic uremic patient could improve care, save ๐ฐ๐ฐ, & free up ICU beds.
emcrit.org/ibcc/fluid/#step_โฆ
16
222
712
am I the only person who finishes a week on ICUโฆ and then the *first* thing I do on my day off is run the electronic list to see how theyโre all doing?
ok, Iโll see myself out now
58
12
669
184,101
epinephrine stops mast cells from degranulating (exploding), whereas antihistamines just block histamine. thatโs why epi is critical in anaphylaxis. #StopTheMastCellExplosion
Cool video of mast cells degranulating โฌ๏ธ
Honestly it sort of looks like how allergies feel ๐คง
#medtwitter
3
192
673
in residency a senior attending gathered us up to teach the exam for ascites. 10 minute demonstration of shifting dullness, fluid wave
then we tried to do a paracentese the pt. no luck. tried again. dry๐ง
US later showed that the patient was just obese. lucky they survived ๐คฆโโ๏ธ๐ญ
Scratch test for organomegaly. First do a "control". Won't hear scratching until very close to scope. Next put scope over organ (eg, spleen). Now you'll hear scratching when you reach edge of the organ (much farther from scope vs control). The organ "carries" the sound to scope.
23
75
669
266,150
loading doses of antiseizure meds for status epilepticus are worth knowing & easy to remember:
20 - 40 - 60
1.5 - 3 - 4.5
anyone >75 kg maxes out, so you know their dose off the top of your head.
please don't make up random doses based on your mood & anxiety level.
8
193
682
how to place a consult: you MUST understand the five stages of consultant grief.
once you can understand this painful and natural process, requesting consults will make a LOT more sense
buckle up, it can be a little roughโฆ
๐งต 1/6โฆ
25
145
639
306,310
a patient presents in AF with rapid ventricular rate, eventually requiring intubation. is this a *primary* cardiac problem, or is the AF *secondary* to an underlying disease? The answer is hiding on this ventilator screen!
Explanation here: bit.ly/3tvL9Qk
38
139
649
i wonder what medicine would be like if we compensated for palliative care the way we compensate for invasive procedures.
i bet it would be a whole lot better.
21
67
585
coding department: Could you clarify whether this patient had a STEMI or an NSTEMI? The chart says both.
me: actually the STEMI/NSTEMI pardigm is profoundly flawed, Iโd classify this as an occlusive MI
coding: thereโs no code for that
me: precisely
coding:
me:
15
26
604
nobody:
absolutely nobody:
EPIC: Howdy everybody guess what?? We moved around all the buttons again! Youโre welcome!!
16
65
587
72,012
itโs only urosepsis if it originates from the Champagne region of France, otherwise itโs just sparkling bactiuria
7
73
584
70,517
martin tobin is flexing hard on gattinoni about patient self-induced lung injury (P-SILI). this is truly the superbowl of ventilator nerdiness. get some popcorn ๐ฟ
(article: bit.ly/30wfVNx)
42
195
582
breaking up the legend and placing text next to each panel makes it infinitely easier to understand.
5
141
587
Crown
amazing how deep the myth of contrast nephropathy has seeped into the medical literature. if you have a critically ill patient who needs a CT angio, just get the CT angio. don't pass go, don't collect 200$, don't check the creatinine - just get the scan.
pubmed.ncbi.nlm.nih.gov/3266โฆ
18
154
586
good morning twitter, please provide some peer review on this (draft) algorithm for approaching the diagnosis of PE. i'm sure there will be no controversy about this whatsoever.
43
115
591
โno... we didnโt recheck the Mg... yes, I want more magnesium... no, I donโt know what the level is... yes, the level is definately too lowโ ๐คฃ
25
46
539
"Penetrating trauma is a distinct possibility, but we should obtain a CT angiogram to exclude pulmonary embolism, just to err on the side of caution."
21
84
568
Hot take on dual diuretic therapy for decongestion of heart failure (ADVOR trial)
๐ฅfurosemide monotherapy is an amateurish strategy for decongestion (esp if this already failed as an outpatient)
๐ฅadding acetazolamide improves natriuresis & efficacy
emcrit.org/pulmcrit/advor/
12
145
545
a recent study shows balanced fluids tend to resolve DKA faster than saline. no shock here - giving acidic fluid to an acidotic patient is subawesome. but I want to deeper here to explore specific reasons *not* to give saline...
(full article: bit.ly/3pJ0Q5d)
14
160
546
icu version:
bill: the CXR was significant for edema
icu attending: yep, its super wet
bill: so I think we should start some lasix
icu: yessss
bill: Iโll order 40 mg
icu: ๐
bill: 80 mg?
icu: ๐
bill: 160 mg???
icu: thatโs perfect Bill, great stuff
Dr. Glaucomflecken
29
52
526
20 meta-analyses of the same four RCTs nitter.app/Xudong1966/status/1764โฆ
10
98
535
66,865
some pearls from an article by Martin Tobin about when to intubate patients with COVID (yep, the same one who edited Tobin's textbook on mechanical ventilation)... (#1/6)
(full article: bit.ly/2XDgovQ)
20
262
548
โthe patient is too unstable for a procedure to stop the bleeding, please continue resuscitationโ
Radio Albacete
27
127
521
fresh study: D-dimer >1,500 strongly correlates with DVT among COVID patients (85% sensi, 89% spec). many limitations, but this supports the concept of empiric anticoagulation if โฌ๏ธโฌ๏ธ DDimer & no contraindication.
(fresh blog: bit.ly/3aXvUGE)
#COVID19FOAM
28
234
529
introducing the IBPH (internet book of hospital pulm)
expansion to the IBCC section on pulm, with a goal of covering inpatient pulmonology more thoroughly๐ซ
please help support the project by sharing & peer-reviewing the new chapters (coming soon)๐ฆ
emcrit.org/pulmcrit/ibhp/
21
104
504
81,979
Right Ventricular failure - fresh chapter!
โค๏ธโ๐ฅcommon in ICU - esp ARDS (25%) & complex patients w/ comorbidities
โค๏ธโ๐ฅdon't need to be very invasive (e.g. Swan)
โค๏ธโ๐ฅdo need to understand physiology & provide RV-friendly resus
#ThePeoplesVentricle #DiuresisJedi
emcrit.org/ibcc/rv/
19
153
526
UPenn study shows that vanc-piptazo โฌ๏ธ *creatinine* but actually causes a trend towards โฌ๏ธCystatin C. this dissociation between Cr vs. renal biomarker implies that piptazo is a pseudonephrotoxin that โฌ๏ธ Cr secretion, w/o hurting the kidney (1/2) @Miano81
vimeo.com/523925430
18
143
504
introducing the Internet Book of NeuroCritical Care (#IBNCC) ๐
๐ง 26 new chapters, to create a full neurocritical care text integrated into the IBCC
๐ง review & podcasts from neurocrit gurus @caseyalbin @drdangayach @rkchoi ๐
๐ง #FOAMed ๐ฒ
details: emcrit.org/pulmcrit/ibncc/
18
134
500
COVID-STEROID 2
๐ฅ5% lower mortality with 12 mg dexamethasone (vs 6 mg) - which is *huge* - but p=0.09 ๐ฉ
๐ฅRCTs with toci/bari show that 6 mg dex alone is suboptimal.
๐ฅIf using dex monotherapy, 12 mg is now a sensible dose for sicker pts.
Fresh blog: emcrit.org/dex12
15
178
512
๐ช pearl for emergent surgical cricothyrotomy: extend the neck!
๐ช ask an assistant to extend the neck for you (thereโs no time for fancy positioning)
๐ช neck extension brings the airway closer to the skin. if there is excess soft tissue, it gets pulled to the side
ALT image credit: from https://www.nh.gov/safety/divisions/fstems/ems/advlifesup/documents/cricoadministration.pdf
10
99
518
OK fine, but we need some *balance*
My recommendations for other elevators:
Ask: could the blood culture be a contaminant?
Ask: could it be rhinovirus?
Ask: could it be excessive antihypertensive medications?
Ask: can we stop antibiotics?
Ask: does WBC really mean anything?
17
74
493
118,831
when the student suggests bolusing 30 cc/kg normal saline to be in compliance with the surviving sepsis bundle
11
40
485
context is critical to interpret INR:
๐ฉธINR 2.5 in cirrhotic: meh, likely hypercoagulable
๐ฉธINR 2.5 on warfarin: anticoagulated
๐ฉธINR 2.5 on apixaban: may be very bleedy
๐ฉธINR 2.5 in DIC: maybe clotty or bleedy
so in diverse populations, INR often won't correlate with hemorrhage
6
97
490
large Italian study on ICU patients with COVID just published. this may be the most accurate predictor of COVID in the USA, and it's a bit sobering...(#1/5)
(study: bit.ly/2x07u0G)
13
277
492
new shortages of IV lorazepam & diazepam ๐ฌ
if youโre not allready using phenobarbital for alcohol withdrawal, now is a good time to learn ๐บ
conserve IV benzos for situations where theyโre truly needed (eg status epilepticus) โก๏ธ
emcrit.org/ibcc/etoh/#top
14
91
476
the fact that the patient improved doesn't indicate that optimal care was provided.
the fact that the patient deteriorated doesn't indicate that suboptimal care was provided.
our brains are programmed to look for causality everywhere, but medicine just isn't this simple.
5
105
482
donโt forget to take joy in patients who come in with common diseases, get standard therapy, and do great. these folks donโt require much brain power, but that doesnโt dimish the importance of their recoveries.
9
53
466
given how immensely shitty 2020 has been, maybe this is a good time to bury our turf battles, support each other, and work together against coronavirus & racism. thatโs the tweet.
Words matter.
In the medical setting, *resident*, *residency*, *fellow*, and *fellowship* belong to physicians ONLY. โฌ๏ธ๐
Every EM physician, resident, & student should be paying attention to the battle on scope of practice. ๐ฅผ
Thatโs the tweet.
emra.org/be-involved/be-an-aโฆ
21
45
454
Started writing a blog about problems in the new sepsis guidelines, but then realized that I *already* wrote this in 2017. And the problems remain nearly unchanged๐คฆโโ๏ธ
So I present you with: Six myths [STILL] promoted by the new sepsis guidelines๐คฏ
emcrit.org/pulmcrit/sepsis-mโฆ
15
148
477
โThe patient is a 95 year old with a prior medical history of mild hypertension, hyperlipidemia, prediabetes, hiatal hernia, diverticulosis, hammer toe, skin tags, traumatic shoulder dislocation, neonatal hyperbilirubinemiaโฆโ
Tampa Bay Rays
12
63
472
98,118
understanding happy hypoxemia physiology: how COVID taught me to treat pneumococcus. (happy hypoxemia has existed forever, but we didn't fully recognize how to treat it... until now). #COVID19foam #zentensivist
(blog: bit.ly/3beKCsS)
15
200
479
Myth-busting the nephrotoxicity of piperacillin-tazobactam plus vancomycin:
๐ชPiptazo is a pseudo-nephrotoxin that increases Cr due to reduced secretion
๐ชPiptazo doesn't โฌ๏ธ hemodialysis or mortality
๐ชNew study: No effect on BUN or renal biomarker
emcrit.org/pulmcrit/myth-pipโฆ
10
142
480
So, the NEJM just published a review on Contrast-Associated AKI โ a disease that Iโm not sure actually existsโฆ this should be interestingโฆ (rantorial 1/4)
nejm.org/doi/full/10.1056/NEโฆ
22
218
470
this is completely ๐ฏ wrong.
we literally use VBG to assess ventilation (CO2) on a daily basis in ICU
the O2 sat on the VBG helps give you a sense of how accurate it is - but as a general rule the accuracy is adequate
more detail here emcrit.org/pulmcrit/vbg-abg/
We CANNOT use the carbon dioxide level on a VENOUS blood gas (VBG) to accurately assess the need for BiPap or intubation
Ventilation problems cannot be assessed on a VBG
19
55
441
127,709
Dear Journals,
Iโm not sure how to break this to you, but:
Nobody cares what your impact factor is.
Because itโs not a measurement of quality.
Sincerely,
Everyone
17
80
449
manipulating volume status affects outcomes less than we might have expected
as long as youโre in the right ballpark, a little less volume & more pressor, or more volume & less pressor - may not matter
fluid never was, nor ever will be, the treatment for sepsis๐ #zentensivist
Just released at #SCCM2023: Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension
nej.md/3CWSXBA
#SCCMSoMe @sccm
15
86
455
165,554
diagnostic challenge: Patient presents to ICU with severe hypotension. History and exam are unrevealing. Based on this CBC ๐, why is this patient in shock? ๐งฉ
answer & explaination here: bit.ly/2lVGEAY
23
172
450
lactate-guided resuscitation: please stop the madness ๐คช #resist
jtd.amegroups.com/article/viโฆ
16
196
451
COVID, ARDS, recruitability & phenotypes
- seven subtypes of "ARDS"
- various definitions of recruitability
- early COVID is pseudoARDS (nothing novel)
- why I disagree with Gattinoni's L-type & low-PEEP/high-FiO2 strategies for intubated pts
(blog: bit.ly/3ezhmPS)
20
210
447
ACEP creates the cure for the common sepsis guideline!
๐Fresh guideline is realistic & evidence-based.
๐ This should *replace* the Surviving Sepsis Campaign guidelines (which are hot trash).
๐E-mail this to folks going nuts about 30 cc/kg fluid ๐
blog: bit.ly/2OT138q
13
125
436
me: eeeek, I think we may need to intubate this guy
nurse: NO JOSH, heโs going to do fine
me: ok ok ๐คทโโ๏ธ
narrator: and indeed, the BiPAP slowly took effect, and several hours later the patient woke up and demanded breakfast
12
16
432
when everyone is stressed to the max, it's especially important to practice kindness and professionalism. viruses, antivirals, steroids, and PEEP strategies all come and go - but professionalism is evergreen ๐ฒ๐ฒ๐ฒ #zentensivist
8
104
430
JAMA: so weโre having fun experimenting with lower editorial standards
American Journal of Medicine: hold my beer
amjmed.com/article/S0002-934โฆ
71
46
400
Both major medical journals agree: this decision will kill women.
The just-announced U.S. Supreme Court decision in Dobbs v. Jackson Womenโs Health Organization represents a stunning reversal of precedent that inserts government into the personal lives and health care of Americans. nej.md/3Aa5cKe
6
236
386
'tis the season for influenza... ๐ please don't over-resuscitate your flupneumonia patients (their problem is hypoxemia, not hypovolemia)
15
119
413