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Reposted by Anthony Lau, PharmD BCPS

josh farkas 💊 @pulmcrit.bsky.social · 3d

normal mentation *doesn't* indicate adequate systemic perfusion

especially in cardiogenic shock, people can mentate well despite terrible CO & systemic perfusion

poor mentation is sometimes an early sign of *septic* shock, but often a very late indicator of other shock states #EMIMCC

Sad Sad Bean GIF

ALT: Sad Sad Bean GIF

a woman in a checkered shirt says way too much sugar in a kitchen

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Reposted by Anthony Lau, PharmD BCPS

josh farkas 💊 @pulmcrit.bsky.social · 7d

Fresh blog: Six pearls on heparin-induced thrombocytopenia (HIT) in 2025

💎 enoxaparin causes 10x less HIT than UFH

💎 HEP score

💎 approach to intermediate 4T score?

💎 rising use of DOACs

💎 autoimmune HITT

💎 IVIG for immediate inhibition of HIT antibodies

blog emcrit.org/pulmcrit/hit... #EMIMCC

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Reposted by Anthony Lau, PharmD BCPS

josh farkas 💊 @pulmcrit.bsky.social · 6d

Updated the IBCC DKA chapter 🍭

Biggest changes were organizational, there is now a pretty clear & streamlined 8-step guide

Biggest content change was a rewrite of the definition of DKA (but - spoiler alert - the definition remains unclear & controversial)…

emcrit.org/ibcc/dka/#top #EMIMCC

ALT: a woman in a checkered shirt says way too much sugar in a kitchen

Reduced Dose Insulin in HyperK #emergencymedicine #criticalcare

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Reposted by Anthony Lau, PharmD BCPS

Anand Swaminathan @emswami.bsky.social · 10d

IV insulin is a backbone tx in hyperK
Standard: 10 units IVP w/ dextrose
2021 meta(PMID: 33993515) looked at 10 units vs < 10 units
No difference in reduction in serum K.
Reduced risk of hypoglycemic + severe hypoglycemic events w/ reduced insulin dose

youtube.com/shorts/Sz9Zy...
#EMIMCC

Use of Phenobarbital for Treating Alcohol Withdrawal

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Reposted by Anthony Lau, PharmD BCPS

josh farkas 💊 @pulmcrit.bsky.social · 13d

"consensus" guideline on the management of DKA & HHS

with ZERO input from:
- anyone in emergency medicine
- anyone in critical care
- anyone in hospital medicine

the guidelines (published in 2024) contain many antiquated practices and big errors... 🧵#1/3 #EMIMCC

pubmed.ncbi.nlm.nih.gov/39052901/

https://diabetesjournals.org/care/article/47/8/1257/156808/Hyperglycemic-Crises-in-Adults-With-Diabetes-A

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Anthony Lau, PharmD BCPS @alaurx.bsky.social · 13d

Experience Lasting Moments, a #fundraising event with stunning #photography & limited-edition prints supporting TWCC’s #palliative care work in South Asia

📅 Oct 25: Join us in Abbotsford, BC! lnkd.in/gZB98e8T

🌐 Everywhere else? Our online Square-Print Sale Oct 15–30 twoworldscancer.ca/cart

Reposted by Anthony Lau, PharmD BCPS

josh farkas 💊 @pulmcrit.bsky.social · 16d

New study supporting phenobarb monotherapy for EtOH withdrawal😍

We’ve been seeing more pts with *combined* withdrawal lately (eg opioid + EtOH)

IMHO phenobarb is esp useful in complex withdrawal to tx EtOH w/d, avoid delirium, and avoid excessive GABA #EMIMCC

#1/2

jamanetwork.com/journals/jam...

This quality improvement study evaluates the implementation, clinical outcomes, and safety of an electronic health record order set for intravenous weight-based phenobarbital loading for treating alco...

jamanetwork.com

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Reposted by Anthony Lau, PharmD BCPS

josh farkas 💊 @pulmcrit.bsky.social · 19d

NLR isn't perfect, but it's a whole lot better than WBC

it can be an early signal of serious trouble

or, if NLR is normal, it argues against sepsis (look for some other problem)

NLR-blind clinicians will think you're a genius 😆

full discussion of NLR here:
emcrit.org/pulmcrit/nlr/

a woman is holding a crystal ball with the words saw that coming written below her

ALT: a woman is holding a crystal ball with the words saw that coming written below her

Volume Load in Sick Asthma #emergencymedicine #criticalcare

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Reposted by Anthony Lau, PharmD BCPS

josh farkas 💊 @pulmcrit.bsky.social · 19d

proposal:

all types of bradykinin-mediated angioedema involve a common vicious spiral 👇

tranexamic acid or aminocaproic acid should be universally effective in blocking this cycle & aborting attacks

there's no need for super-expensive drugs (icatibant et al.)

thoughts? criticism? #EMIMCC

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Reposted by Anthony Lau, PharmD BCPS

josh farkas 💊 @pulmcrit.bsky.social · 19d

"bUt tHe WhiTe cOuNT iS nOrmAL"

I see this pattern of laboratory evaluation almost every day in the ICU

anyone involved in evaluating acutely ill patients must be able to recognize this evolution, like the face of an old friend

what is going on here? #EMIMCC 🧵 #1/5

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Reposted by Anthony Lau, PharmD BCPS

Anand Swaminathan @emswami.bsky.social · 19d

Don’t forget to fluid load in sick asthma
-Huge insensible losses from incr RR + WOB
-If need intubation, pos pressure vent results in incr intrathoracic pressure dropping pulmonary venous return ➡️HD collapse
-Load early w/ 20-30 cc/kg of crystalloid to avoid

youtube.com/shorts/mbOzE...
#EMIMCC

a man in a suit is drinking from a cup that says ' mrs. pepper ' on it

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Reposted by Anthony Lau, PharmD BCPS

josh farkas 💊 @pulmcrit.bsky.social · 23d

updated IBCC chapter on anaphylaxis, some new additions:

🆕 methylene blue for anaphylaxis refractory to epi & fluid

🆕 sugammadex for anaphylaxis 2/2 roc or vec

🆕 nebulized epi (in combination with IV) for upper airway edema? Don't bank on it but might help?

(emcrit.org/ibcc/anaphyl...) #EMIMCC

https://pubmed.ncbi.nlm.nih.gov/33653974/

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Reposted by Anthony Lau, PharmD BCPS

josh farkas 💊 @pulmcrit.bsky.social · 23d

Short skytorial about a fresh IBCC chapter covering all things methylxanthine-related (caffeine & theophylline).

This is a niche topic that we don't encounter in everyday practice, but it ties together some loose ends.

(chapter is here: emcrit.org/ibcc/caffeine/) #EMIMCC

ALT: a man in a suit is drinking from a cup that says ' mrs. pepper ' on it

www.frontiersin.org/journals/neu...

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Reposted by Anthony Lau, PharmD BCPS

Stanford Antimicrobial Safety & Sustainability Program @stanfordasp.bsky.social · 24d

📊 See the figure below to review antifungal coverage.

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Anthony Lau, PharmD BCPS @alaurx.bsky.social · 24d

Frontiers | Ketogenic diet treatment for super-refractory status epilepticus in the intensive care unit: feasibility, safety and effectiveness

Background and aimsTo investigate the feasibility, safety and effectiveness of the ketogenic diet (KD) for super-refractory status epilepticus (SRSE) in the ...

www.frontiersin.org

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Anthony Lau, PharmD BCPS @alaurx.bsky.social · 24d

KD can alter albumin levels, affecting drug levels. Drugs highly bound to albumin (e.g. clinda, doxy, phenytoin, valproate, warfarin, diuretics, NSAIDs) may have altered free concentrations due to KD-induced changes in albumin/fatty acid binding, potentially impacting therapeutic effect & toxicity

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Anthony Lau, PharmD BCPS @alaurx.bsky.social · 24d

What does this mean re: drugs? Switch diluent to NS from D5W, no propofol due to disrupting carb:fat ratio and balance, avoid crushable tabs and oral liquids due to sugar in syrups & be careful of highly protein-bound drugs! 🤔

a man is sitting at a table with a plate of food and a cell phone with a pizza on it ..

ALT: a man is sitting at a table with a plate of food and a cell phone with a pizza on it ..

a baby is smiling in front of a sign that says when your coach tells you that one of your favorite snacks is low on carbs

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Anthony Lau, PharmD BCPS @alaurx.bsky.social · 24d

- MOA: ↓carbs, ↑ketones, modulate neurons & neurotransmitters, inhibit mTOR, ↓excitatory signaling

- AEs: GI intolerance, metabolic acidosis, hyperlipidemia, hypoglycemia, lyte disturbances

- data promising but limited...no RCTs yet. Multidisciplinary care & close monitoring essential

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Anthony Lau, PharmD BCPS @alaurx.bsky.social · 24d

Learnt something new today! Ketogenic diet (KD) in super refractory status epi!

There's some emerging data suggesting KD may help adults w/ SRSE...based mostly on small icu studies & peds data. Case series report 70-85% SE resolution often w/in 2-5 days of ketosis #medsky #pharmsky #EMsky #neurosky

ALT: a baby is smiling in front of a sign that says when your coach tells you that one of your favorite snacks is low on carbs

Andexanet Alfa + Thrombembolism #emergencymedicine #criticalcare

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Reposted by Anthony Lau, PharmD BCPS

Anand Swaminathan @emswami.bsky.social · 24d

Time to Ditch Andexanet Alfa?
-ANNEXA-1: No mortality benefit, incr VTE
-Real world data: Rech 2025 (PMID:40700941) no improved outcomes, 9% incr VTE w/ andexanet alfa (NNH = 11)

Mounting evidence that andexanet offers no benefit while increasing complications

youtube.com/shorts/7DGcv...
#EMIMCC

Why Are More Older People Dying After Falls?

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Reposted by Anthony Lau, PharmD BCPS

Swapnil Hiremath 🍁🇨🇦 @hswapnil.medsky.social · 27d

The need to deprescribe!

www.nytimes.com/2025/09/07/h... (gift link)

Older peeps and falls, often prescription drugs to blame.

www.nytimes.com

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Reposted by Anthony Lau, PharmD BCPS

Anand Swaminathan @emswami.bsky.social · 29d

Epinephrine in asthma
-Crashing asthmatic pts may not respond to inhaled bronchodilators: severe bronchoconstriction limits med delivery
-Parenteral bronchodilators ➡️ rapid bronchodilation + can be life-saving
-Parenteral Epi dose: 0.5 mg IM or 50 mcg IV

youtube.com/shorts/MlQu5...
#EMIMCC

Epinephrine in Asthma #emergencymedicine #criticalcare

a girl with pigtails is wearing a hat and says be afraid .

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Reposted by Anthony Lau, PharmD BCPS

josh farkas 💊 @pulmcrit.bsky.social · 28d

Droperidol vs haloperidol: what is the fairest butyrophenone of them all?

This is largely based on receptor affinity rather than RCT data

Mechanistically, droperidol has more multimodality elegance, whereas haloperidol is a D2-receptor blocking hammer

Thoughts?

emcrit.org/ibcc/deliriu... #EMIMCC

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Reposted by Anthony Lau, PharmD BCPS

josh farkas 💊 @pulmcrit.bsky.social · 27d

gram negative rods *rarely* cause blood culture contamination

so a single blood culture growing gram-negative rods should generally be regarded as real & treated as such

(this is *unlike* GPCs, where one culture is often a false-positive due to skin organisms like coag neg staph) #EMIMCC

ALT: a girl with pigtails is wearing a hat and says be afraid .