Alex Koyfman
@emhighak.bsky.social
EM Physician+Educator+Pt Advocate // emdocs.net EIC & Co-founder // #EMRA45u45 // #GirlDad // #citizenofworld // #selfmade
Pinned
Alex Koyfman
@emhighak.bsky.social
· Mar 27
Emergency Medicine Thinker
Emergency Medicine Thinker: 9781009379915: Medicine & Health Science Books @ Amazon.com
www.amazon.com
Released today. Pls check out what makes EM unique and at the core of medicine: www.amazon.com/Emergency-Me.... Deep thx to remarkable authors/leaders in our field. #foamed #medsky #emimcc
Don’t reflexively start B-blockers without looking at old data points and collecting new ones as subset of these pts have mod/severe decr in EF and will decomp. Esmolol over propranolol as you can stop drip. #emimcc
Thyroid storm patients often have high output cardiac failure
-POCUS: LV slamming away more likely to be high output failure
-Beta blockade: slows rate, improves LV filling + cardiac output
-Can use esmolol instead of propranolol as it’s got a short 1/2 life
youtube.com/shorts/Alwol...
#EMIMCC
-POCUS: LV slamming away more likely to be high output failure
-Beta blockade: slows rate, improves LV filling + cardiac output
-Can use esmolol instead of propranolol as it’s got a short 1/2 life
youtube.com/shorts/Alwol...
#EMIMCC
Beta Blockers in Thyroid Storm #emergencymedicine #criticalcare
YouTube video by EMSwami
youtube.com
October 24, 2025 at 2:49 PM
Don’t reflexively start B-blockers without looking at old data points and collecting new ones as subset of these pts have mod/severe decr in EF and will decomp. Esmolol over propranolol as you can stop drip. #emimcc
Nuanced understanding of spectrum of any disease is so important. Not a one-size fits-all approach. Reflect on your current practice. Aggressively learn from cases with any angst/conflict. This is how you elevate care and your field. #emimcc
Just updated the IBCC chapter on cholecystitis & cholangitis.
These patients are often initially triaged to the ICU.
Understanding these diseases can help us direct patients to interventions they need.
Let’s talk about four pearls 😁
chapter: emcrit.org/ibcc/biliary... #EMIMCC
These patients are often initially triaged to the ICU.
Understanding these diseases can help us direct patients to interventions they need.
Let’s talk about four pearls 😁
chapter: emcrit.org/ibcc/biliary... #EMIMCC
a woman in a pearl costume says pearls
ALT: a woman in a pearl costume says pearls
media.tenor.com
October 19, 2025 at 4:34 PM
Nuanced understanding of spectrum of any disease is so important. Not a one-size fits-all approach. Reflect on your current practice. Aggressively learn from cases with any angst/conflict. This is how you elevate care and your field. #emimcc
Reposted by Alex Koyfman
#4/4) ascenting cholangitis generally IS infected & OFTEN causes septic shock
be wary of patients w/ ascending cholangitis who seem OK (may crash)
source control is usually obtained via ERCP. this should be done regardless of how sick the patient is (nobody is “too sick” for source control).
be wary of patients w/ ascending cholangitis who seem OK (may crash)
source control is usually obtained via ERCP. this should be done regardless of how sick the patient is (nobody is “too sick” for source control).
a man wearing sunglasses and a green jacket is standing in a crowd and says `` do it '' .
ALT: a man wearing sunglasses and a green jacket is standing in a crowd and says `` do it '' .
media.tenor.com
October 19, 2025 at 1:11 PM
#4/4) ascenting cholangitis generally IS infected & OFTEN causes septic shock
be wary of patients w/ ascending cholangitis who seem OK (may crash)
source control is usually obtained via ERCP. this should be done regardless of how sick the patient is (nobody is “too sick” for source control).
be wary of patients w/ ascending cholangitis who seem OK (may crash)
source control is usually obtained via ERCP. this should be done regardless of how sick the patient is (nobody is “too sick” for source control).
Reposted by Alex Koyfman
#3/4) percutaneous drainage is over-utilized for acute calculous cholecystitis (2/2 pressure to do something now)
no high-quality data supporting drain insertion (RCTs failed to find benefit)
the ideal therapy for most patients is medical stabilization followed by early laproscopic cholecystectomy
no high-quality data supporting drain insertion (RCTs failed to find benefit)
the ideal therapy for most patients is medical stabilization followed by early laproscopic cholecystectomy
a group of surgeons are dancing in an operating room with the words happy surgery team great results
ALT: a group of surgeons are dancing in an operating room with the words happy surgery team great results
media.tenor.com
October 19, 2025 at 1:11 PM
#3/4) percutaneous drainage is over-utilized for acute calculous cholecystitis (2/2 pressure to do something now)
no high-quality data supporting drain insertion (RCTs failed to find benefit)
the ideal therapy for most patients is medical stabilization followed by early laproscopic cholecystectomy
no high-quality data supporting drain insertion (RCTs failed to find benefit)
the ideal therapy for most patients is medical stabilization followed by early laproscopic cholecystectomy
Reposted by Alex Koyfman
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
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
media.tenor.com
October 8, 2025 at 9:05 PM
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
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
Crucial to learn from all fields of medicine in order to provide thoughtful, comprehensive care for the pts in front of us #emimcc
"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/
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/
September 29, 2025 at 12:28 AM
Crucial to learn from all fields of medicine in order to provide thoughtful, comprehensive care for the pts in front of us #emimcc
Reposted by Alex Koyfman
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...
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...
Use of Phenobarbital for Treating Alcohol Withdrawal
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
September 25, 2025 at 1:10 PM
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...
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...
1 more point that will sharpen your clinical gestalt and decision making. Details matter, particularly in EM. #emimcc
"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
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
September 22, 2025 at 7:20 PM
1 more point that will sharpen your clinical gestalt and decision making. Details matter, particularly in EM. #emimcc
Reposted by Alex Koyfman
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
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
a girl with pigtails is wearing a hat and says be afraid .
ALT: a girl with pigtails is wearing a hat and says be afraid .
media.tenor.com
September 14, 2025 at 12:02 PM
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
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
Spectrum of disease w nuanced management. Hard to flesh out.
My approach to mild septic shock from acute cholecystitis is often to trial medical tx with antibiotics, fluid, and low-dose vasopressors.
Most pts will improve and avoid getting a drain.
The whole situation is giving appendicitis vibes (dogma was to operate STAT, but actually not needed). #3/3
Most pts will improve and avoid getting a drain.
The whole situation is giving appendicitis vibes (dogma was to operate STAT, but actually not needed). #3/3
a cartoon of homer simpson standing in a grassy yard
ALT: a cartoon of homer simpson standing in a grassy yard
media.tenor.com
September 5, 2025 at 10:06 PM
Spectrum of disease w nuanced management. Hard to flesh out.
Quite thoughtful on your end @pulmcrit.bsky.social. Something that would definitely benefit from standardization and benefit critically ill pts.
this is useful information, but...
if you have an ED patient who clearly requires ICU (e.g., ICP elevation, critical asthma) don't delay calling us 👋
getting on board early can help expedite logistic stuff & smooth out the transfer process
also, walking down to the ED helps me get my steps in
if you have an ED patient who clearly requires ICU (e.g., ICP elevation, critical asthma) don't delay calling us 👋
getting on board early can help expedite logistic stuff & smooth out the transfer process
also, walking down to the ED helps me get my steps in
September 2, 2025 at 4:22 PM
Quite thoughtful on your end @pulmcrit.bsky.social. Something that would definitely benefit from standardization and benefit critically ill pts.
Reposted by Alex Koyfman
Answer: #2 normotensive cardiogenic shock
It’s sneaky, easy to miss but important to identify, diagnose cause, manage and admit to ICU—not the floor tele unit
Occurs in about 12% of CS patients
Mortality 17%
www.jacc.org/doi/10.1016/...
It’s sneaky, easy to miss but important to identify, diagnose cause, manage and admit to ICU—not the floor tele unit
Occurs in about 12% of CS patients
Mortality 17%
www.jacc.org/doi/10.1016/...
Continuum of Preshock to Classic Cardiogenic Shock in the Critical Care Cardiology Trials Network Registry:
www.jacc.org
August 10, 2025 at 7:49 PM
Answer: #2 normotensive cardiogenic shock
It’s sneaky, easy to miss but important to identify, diagnose cause, manage and admit to ICU—not the floor tele unit
Occurs in about 12% of CS patients
Mortality 17%
www.jacc.org/doi/10.1016/...
It’s sneaky, easy to miss but important to identify, diagnose cause, manage and admit to ICU—not the floor tele unit
Occurs in about 12% of CS patients
Mortality 17%
www.jacc.org/doi/10.1016/...
Reposted by Alex Koyfman
if you see a gram-negative that is resistant to ceftriaxone, this is a red flag for possible ESBL.
even if lab report states that the bacteria is "sensitive" to ceftazidime, cefepime, or piptazo, it may be advisable to avoid these.
even if lab report states that the bacteria is "sensitive" to ceftazidime, cefepime, or piptazo, it may be advisable to avoid these.
August 6, 2025 at 8:06 PM
if you see a gram-negative that is resistant to ceftriaxone, this is a red flag for possible ESBL.
even if lab report states that the bacteria is "sensitive" to ceftazidime, cefepime, or piptazo, it may be advisable to avoid these.
even if lab report states that the bacteria is "sensitive" to ceftazidime, cefepime, or piptazo, it may be advisable to avoid these.
Reposted by Alex Koyfman
I'm working on creating a critical care drug handbook (embedded into the IBCC, for free).
Working version here: emcrit.org/ibcc/drugs/
Are there other drugs that you'd like to see included?
(Apologies in advance for not including drugs that are exclusively available outside the USA) #EMIMCC
Working version here: emcrit.org/ibcc/drugs/
Are there other drugs that you'd like to see included?
(Apologies in advance for not including drugs that are exclusively available outside the USA) #EMIMCC
Critical Care Drug Handbook
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Acetaminophen Acetazolamide Acetylcysteine Acyclovir […]
emcrit.org
July 30, 2025 at 2:34 PM
I'm working on creating a critical care drug handbook (embedded into the IBCC, for free).
Working version here: emcrit.org/ibcc/drugs/
Are there other drugs that you'd like to see included?
(Apologies in advance for not including drugs that are exclusively available outside the USA) #EMIMCC
Working version here: emcrit.org/ibcc/drugs/
Are there other drugs that you'd like to see included?
(Apologies in advance for not including drugs that are exclusively available outside the USA) #EMIMCC
Reposted by Alex Koyfman
The cognitive pause in refractory hypotension reminds us to stop, question our diagnosis + assumptions and consider alternate/additional pathologies
- Acidosis
- Hypothyroidism
- Iatrogenic anaphylaxis
- Hypocalcemia
- Occult hemorrhage
- RUSH Exam
youtube.com/shorts/bvWoL...
#EMIMCC
- Acidosis
- Hypothyroidism
- Iatrogenic anaphylaxis
- Hypocalcemia
- Occult hemorrhage
- RUSH Exam
youtube.com/shorts/bvWoL...
#EMIMCC
The Cognitive Pause: Refractory Hypotension #criticalcare #emergencymedicine
YouTube video by EMSwami
youtube.com
July 10, 2025 at 10:50 PM
The cognitive pause in refractory hypotension reminds us to stop, question our diagnosis + assumptions and consider alternate/additional pathologies
- Acidosis
- Hypothyroidism
- Iatrogenic anaphylaxis
- Hypocalcemia
- Occult hemorrhage
- RUSH Exam
youtube.com/shorts/bvWoL...
#EMIMCC
- Acidosis
- Hypothyroidism
- Iatrogenic anaphylaxis
- Hypocalcemia
- Occult hemorrhage
- RUSH Exam
youtube.com/shorts/bvWoL...
#EMIMCC
Reposted by Alex Koyfman
to recap: the dosing of antiepileptics for true, ongoing, life-threatening convulsive status epilepticus in an adult:
1st line:
👊Lorazepam 0.1 mg/kg IV (VA-COOP RCT)
👊Or if no IV access: Midazolam 10 mg IM (RAMPART RCT)
2nd line:
👊Levetiracetam 60 mg/kg up to a max dose of 4.5 grams (ESSETT RCT)
1st line:
👊Lorazepam 0.1 mg/kg IV (VA-COOP RCT)
👊Or if no IV access: Midazolam 10 mg IM (RAMPART RCT)
2nd line:
👊Levetiracetam 60 mg/kg up to a max dose of 4.5 grams (ESSETT RCT)
two women are sitting next to each other and one is pointing at the camera
ALT: two women are sitting next to each other and one is pointing at the camera
media.tenor.com
May 29, 2025 at 10:06 PM
to recap: the dosing of antiepileptics for true, ongoing, life-threatening convulsive status epilepticus in an adult:
1st line:
👊Lorazepam 0.1 mg/kg IV (VA-COOP RCT)
👊Or if no IV access: Midazolam 10 mg IM (RAMPART RCT)
2nd line:
👊Levetiracetam 60 mg/kg up to a max dose of 4.5 grams (ESSETT RCT)
1st line:
👊Lorazepam 0.1 mg/kg IV (VA-COOP RCT)
👊Or if no IV access: Midazolam 10 mg IM (RAMPART RCT)
2nd line:
👊Levetiracetam 60 mg/kg up to a max dose of 4.5 grams (ESSETT RCT)
Released today. Pls check out what makes EM unique and at the core of medicine: www.amazon.com/Emergency-Me.... Deep thx to remarkable authors/leaders in our field. #foamed #medsky #emimcc
Emergency Medicine Thinker
Emergency Medicine Thinker: 9781009379915: Medicine & Health Science Books @ Amazon.com
www.amazon.com
March 27, 2025 at 2:37 PM
Released today. Pls check out what makes EM unique and at the core of medicine: www.amazon.com/Emergency-Me.... Deep thx to remarkable authors/leaders in our field. #foamed #medsky #emimcc
Reposted by Alex Koyfman
I have been doing this for 10 years now - some reflections on #FOAMed and the future of First10EM
I have been doing this for 10 years
I have been doing this for 10 years now. I am not sure what the future holds. I am not sure what First10EM will look like in another 10 years. I am not sure these words will be published (although if you are reading it, I guess we have our answer). This is an exercise in self reflection. If it is posted publicly, it is either because I think a small number of long time readers might find it interesting, or because I hope to get some feedback on my musings.
first10em.com
March 17, 2025 at 10:10 AM
I have been doing this for 10 years now - some reflections on #FOAMed and the future of First10EM
Reposted by Alex Koyfman
PulmCrit blog: Michelin Chest Syndrome
A shallow pigtail chest tube straightens out & lacerates the lung…
Side-holes in the chest wall function as a conduit, pushing air into the subcutaneous tissue…
Massive subcutaneous emphysema occurs
blog: https://emcrit.org/pulmcrit/michelin-chest-syndrome/
A shallow pigtail chest tube straightens out & lacerates the lung…
Side-holes in the chest wall function as a conduit, pushing air into the subcutaneous tissue…
Massive subcutaneous emphysema occurs
blog: https://emcrit.org/pulmcrit/michelin-chest-syndrome/
March 15, 2025 at 8:39 PM
PulmCrit blog: Michelin Chest Syndrome
A shallow pigtail chest tube straightens out & lacerates the lung…
Side-holes in the chest wall function as a conduit, pushing air into the subcutaneous tissue…
Massive subcutaneous emphysema occurs
blog: https://emcrit.org/pulmcrit/michelin-chest-syndrome/
A shallow pigtail chest tube straightens out & lacerates the lung…
Side-holes in the chest wall function as a conduit, pushing air into the subcutaneous tissue…
Massive subcutaneous emphysema occurs
blog: https://emcrit.org/pulmcrit/michelin-chest-syndrome/
Please check this out: www.amazon.com/Emergency-Me.... Our field is so complex and crucial to success of medicine. #emimcc #medsky
Emergency Medicine Thinker: Pearls for the Frontlines
Emergency Medicine Thinker: Pearls for the Frontlines: 9781009379915: Medicine & Health Science Books @ Amazon.com
www.amazon.com
March 8, 2025 at 3:09 AM
Please check this out: www.amazon.com/Emergency-Me.... Our field is so complex and crucial to success of medicine. #emimcc #medsky
Check out latest in EM decision making series: www.sciencedirect.com/science/arti.... Thx BLong, JEaster. #medsky #emimcc
High risk and low incidence diseases: Pediatric intussusception
Pediatric intussusception is a serious condition that carries with it a high risk of morbidity and mortality.This review highlights the pearls and pit…
www.sciencedirect.com
February 22, 2025 at 3:41 PM
Check out latest in EM decision making series: www.sciencedirect.com/science/arti.... Thx BLong, JEaster. #medsky #emimcc
Very interested to hear what folks think of this for EM: www.acgme.org/globalassets... #medsky #emimcc
www.acgme.org
February 17, 2025 at 12:38 AM
Very interested to hear what folks think of this for EM: www.acgme.org/globalassets... #medsky #emimcc
Reposted by Alex Koyfman
version for new AF in ICU pt who needs urgent (not emergent) cardioversion:
1) start protocoled Mg gtt 1 g/hr
2) amio load & gtt
3) wait a few hrs
4) 1 mg ibutilide
5) if still in AF: DCCV
meds build up & work together
Mg/ibutilide/amio are synergistic
Mg prevents ibutilide-induced TdP #EMIMCC
1) start protocoled Mg gtt 1 g/hr
2) amio load & gtt
3) wait a few hrs
4) 1 mg ibutilide
5) if still in AF: DCCV
meds build up & work together
Mg/ibutilide/amio are synergistic
Mg prevents ibutilide-induced TdP #EMIMCC
Recent Onset AF Cardioversion:
- Amiodarone: Success rate 60-65%, delayed onset
- Procainamide: Success rate 60-65%, works (or doesn’t) in ~ 60 min
- Electricity: 95-97% success rate, immediate, no side effects
#MedSky #EMIMCC
youtube.com/shorts/cRAtL...
- Amiodarone: Success rate 60-65%, delayed onset
- Procainamide: Success rate 60-65%, works (or doesn’t) in ~ 60 min
- Electricity: 95-97% success rate, immediate, no side effects
#MedSky #EMIMCC
youtube.com/shorts/cRAtL...
AF Cardioversion #criticalcare #emergencymedicine #resuscitation #cardiology
YouTube video by EMSwami
youtube.com
February 11, 2025 at 11:34 PM
version for new AF in ICU pt who needs urgent (not emergent) cardioversion:
1) start protocoled Mg gtt 1 g/hr
2) amio load & gtt
3) wait a few hrs
4) 1 mg ibutilide
5) if still in AF: DCCV
meds build up & work together
Mg/ibutilide/amio are synergistic
Mg prevents ibutilide-induced TdP #EMIMCC
1) start protocoled Mg gtt 1 g/hr
2) amio load & gtt
3) wait a few hrs
4) 1 mg ibutilide
5) if still in AF: DCCV
meds build up & work together
Mg/ibutilide/amio are synergistic
Mg prevents ibutilide-induced TdP #EMIMCC
Fave afib management pearls? #medsky #emimcc @pulmcrit.bsky.social @emcases.bsky.social @petrosoniak.bsky.social @first10em.bsky.social @skylerlentz.bsky.social
January 31, 2025 at 10:59 AM
Fave afib management pearls? #medsky #emimcc @pulmcrit.bsky.social @emcases.bsky.social @petrosoniak.bsky.social @first10em.bsky.social @skylerlentz.bsky.social