EstaM
@estam.bsky.social
Reposted by EstaM
it's wild how badly people dose hypertonic therapy
60 ml of 23% is equivalent to ~500 ml 3%, so this article makes no coherent sense
best approach: figure out the sodium change you want and calculate the hypertonic dose
math sets you free from dozens of contradictory consensus statements #EMIMCC
60 ml of 23% is equivalent to ~500 ml 3%, so this article makes no coherent sense
best approach: figure out the sodium change you want and calculate the hypertonic dose
math sets you free from dozens of contradictory consensus statements #EMIMCC
February 11, 2026 at 9:15 PM
it's wild how badly people dose hypertonic therapy
60 ml of 23% is equivalent to ~500 ml 3%, so this article makes no coherent sense
best approach: figure out the sodium change you want and calculate the hypertonic dose
math sets you free from dozens of contradictory consensus statements #EMIMCC
60 ml of 23% is equivalent to ~500 ml 3%, so this article makes no coherent sense
best approach: figure out the sodium change you want and calculate the hypertonic dose
math sets you free from dozens of contradictory consensus statements #EMIMCC
Reposted by EstaM
are you using a DEFCON-based strategy to manage bowel motility in hospitalized patients?
having a clear, evidence-based treatment strategy improves efficacy & saves time
you don't need to redesign the wheel for every patient
& helpful to avert thermonuclear war
emcrit.org/ibcc/constip... #EMIMCC
having a clear, evidence-based treatment strategy improves efficacy & saves time
you don't need to redesign the wheel for every patient
& helpful to avert thermonuclear war
emcrit.org/ibcc/constip... #EMIMCC
February 10, 2026 at 2:32 PM
are you using a DEFCON-based strategy to manage bowel motility in hospitalized patients?
having a clear, evidence-based treatment strategy improves efficacy & saves time
you don't need to redesign the wheel for every patient
& helpful to avert thermonuclear war
emcrit.org/ibcc/constip... #EMIMCC
having a clear, evidence-based treatment strategy improves efficacy & saves time
you don't need to redesign the wheel for every patient
& helpful to avert thermonuclear war
emcrit.org/ibcc/constip... #EMIMCC
Reposted by EstaM
Fresh Blog: Mythbusting the use of beta-blockers for sinus tachycardia in thyroid storm
This is one of the most dangerous & pervasive myths currently in circulation about acute care
B-bl commonly precipitate shock or even arrest in these patients...(#1/2)
blog: emcrit.org/pulmcrit/tst... #EMIMCC
This is one of the most dangerous & pervasive myths currently in circulation about acute care
B-bl commonly precipitate shock or even arrest in these patients...(#1/2)
blog: emcrit.org/pulmcrit/tst... #EMIMCC
February 9, 2026 at 2:30 PM
Fresh Blog: Mythbusting the use of beta-blockers for sinus tachycardia in thyroid storm
This is one of the most dangerous & pervasive myths currently in circulation about acute care
B-bl commonly precipitate shock or even arrest in these patients...(#1/2)
blog: emcrit.org/pulmcrit/tst... #EMIMCC
This is one of the most dangerous & pervasive myths currently in circulation about acute care
B-bl commonly precipitate shock or even arrest in these patients...(#1/2)
blog: emcrit.org/pulmcrit/tst... #EMIMCC
Reposted by EstaM
The new 2026 AHA/ASA stroke guidelines include this table 👇 for the management of thrombolytic-induced angioedema.
There is NO discussion or any additional text about this topic.
I find this to be insufficient, not evidence-based, and potentially confusing... #1/2 #EMIMCC
There is NO discussion or any additional text about this topic.
I find this to be insufficient, not evidence-based, and potentially confusing... #1/2 #EMIMCC
January 30, 2026 at 10:23 PM
The new 2026 AHA/ASA stroke guidelines include this table 👇 for the management of thrombolytic-induced angioedema.
There is NO discussion or any additional text about this topic.
I find this to be insufficient, not evidence-based, and potentially confusing... #1/2 #EMIMCC
There is NO discussion or any additional text about this topic.
I find this to be insufficient, not evidence-based, and potentially confusing... #1/2 #EMIMCC
Reposted by EstaM
Updated the acute ischemic stroke chapter based on 2026 ASA/AHA guidelines
Chapter focuses on supportive care (*not* who gets lysis/EVT)
This has not changed very much
Top blue numbered section is designed to be used as a checklist when you settle these pts into ICU
emcrit.org/ibcc/ais/ #EMIMCC
Chapter focuses on supportive care (*not* who gets lysis/EVT)
This has not changed very much
Top blue numbered section is designed to be used as a checklist when you settle these pts into ICU
emcrit.org/ibcc/ais/ #EMIMCC
January 31, 2026 at 7:26 PM
Updated the acute ischemic stroke chapter based on 2026 ASA/AHA guidelines
Chapter focuses on supportive care (*not* who gets lysis/EVT)
This has not changed very much
Top blue numbered section is designed to be used as a checklist when you settle these pts into ICU
emcrit.org/ibcc/ais/ #EMIMCC
Chapter focuses on supportive care (*not* who gets lysis/EVT)
This has not changed very much
Top blue numbered section is designed to be used as a checklist when you settle these pts into ICU
emcrit.org/ibcc/ais/ #EMIMCC
Reposted by EstaM
updated the IBCC chapter on BRASH
added a treatment checklist that walks you through resus of a sick BRASH pt
BRASH is uncommon & there are lots of moving pieces, so the checklist is a helpful cue to provide comprehensive treatment of all the BRASH components
emcrit.org/ibcc/brash/ #EMIMCC
added a treatment checklist that walks you through resus of a sick BRASH pt
BRASH is uncommon & there are lots of moving pieces, so the checklist is a helpful cue to provide comprehensive treatment of all the BRASH components
emcrit.org/ibcc/brash/ #EMIMCC
December 30, 2025 at 1:27 PM
updated the IBCC chapter on BRASH
added a treatment checklist that walks you through resus of a sick BRASH pt
BRASH is uncommon & there are lots of moving pieces, so the checklist is a helpful cue to provide comprehensive treatment of all the BRASH components
emcrit.org/ibcc/brash/ #EMIMCC
added a treatment checklist that walks you through resus of a sick BRASH pt
BRASH is uncommon & there are lots of moving pieces, so the checklist is a helpful cue to provide comprehensive treatment of all the BRASH components
emcrit.org/ibcc/brash/ #EMIMCC
Reposted by EstaM
IBCC service update:
Checklists are being converted to numbered grey subsections
These are intended to function as a checklist to guide real-time patient management
Advantages:
☑️easier to read on phone
☑️more flexible (can include images/links)
☑️can be read & used by LLMs
Checklists are being converted to numbered grey subsections
These are intended to function as a checklist to guide real-time patient management
Advantages:
☑️easier to read on phone
☑️more flexible (can include images/links)
☑️can be read & used by LLMs
December 28, 2025 at 2:03 PM
IBCC service update:
Checklists are being converted to numbered grey subsections
These are intended to function as a checklist to guide real-time patient management
Advantages:
☑️easier to read on phone
☑️more flexible (can include images/links)
☑️can be read & used by LLMs
Checklists are being converted to numbered grey subsections
These are intended to function as a checklist to guide real-time patient management
Advantages:
☑️easier to read on phone
☑️more flexible (can include images/links)
☑️can be read & used by LLMs
Reposted by EstaM
has there ever been a high-quality RCT that demonstrated clinically meaningful benefits from pulse-dose steroid (e.g., 500-1000 mg/day methylprednisolone) as compared to a moderate dose of steroid (e.g., 1-2 mg/kg/day prednisone)?
for *any* disease?
for *any* disease?
a man in a suit and tie is standing in front of a blackboard with the words " anyone ? anyone ? "
ALT: a man in a suit and tie is standing in front of a blackboard with the words " anyone ? anyone ? "
media.tenor.com
December 26, 2025 at 5:17 PM
has there ever been a high-quality RCT that demonstrated clinically meaningful benefits from pulse-dose steroid (e.g., 500-1000 mg/day methylprednisolone) as compared to a moderate dose of steroid (e.g., 1-2 mg/kg/day prednisone)?
for *any* disease?
for *any* disease?
Reposted by EstaM
New York state just recorded the highest number of flu cases in a week since it started recording in 2004.
😳
This includes the 2009 H1N1 pandemic (I was a pulm fellow in NY then and it wasn't a great time).
😳
This includes the 2009 H1N1 pandemic (I was a pulm fellow in NY then and it wasn't a great time).
December 27, 2025 at 7:01 PM
New York state just recorded the highest number of flu cases in a week since it started recording in 2004.
😳
This includes the 2009 H1N1 pandemic (I was a pulm fellow in NY then and it wasn't a great time).
😳
This includes the 2009 H1N1 pandemic (I was a pulm fellow in NY then and it wasn't a great time).
Reposted by EstaM
Holiday gift for ya: the IBCC chatbot app 😁
Free AI chatbot searches IBCC contents
Answers seem pretty good & it links to relevent chapters for additional info
Works as an Ebook index on steroids
Created by emergency med folks at Columbia (credit to Joshua Farber & David Fisher) #EMIMCC
Free AI chatbot searches IBCC contents
Answers seem pretty good & it links to relevent chapters for additional info
Works as an Ebook index on steroids
Created by emergency med folks at Columbia (credit to Joshua Farber & David Fisher) #EMIMCC
December 24, 2025 at 2:52 PM
Holiday gift for ya: the IBCC chatbot app 😁
Free AI chatbot searches IBCC contents
Answers seem pretty good & it links to relevent chapters for additional info
Works as an Ebook index on steroids
Created by emergency med folks at Columbia (credit to Joshua Farber & David Fisher) #EMIMCC
Free AI chatbot searches IBCC contents
Answers seem pretty good & it links to relevent chapters for additional info
Works as an Ebook index on steroids
Created by emergency med folks at Columbia (credit to Joshua Farber & David Fisher) #EMIMCC
Reposted by EstaM
G-POEM for Gastroparesis
😟Refractory GP hard to treat, miserable for pts
🤔Meta analysis of 23 studies, 871 pts s/p POEMs
Observational study
👍Long term benefit (5 years) in 81%. Predicting success was idiopathic, shorter duration, higher baseline severity
#GIsky #IMSky #Medsky
Poetry anyone?
😟Refractory GP hard to treat, miserable for pts
🤔Meta analysis of 23 studies, 871 pts s/p POEMs
Observational study
👍Long term benefit (5 years) in 81%. Predicting success was idiopathic, shorter duration, higher baseline severity
#GIsky #IMSky #Medsky
Poetry anyone?
December 15, 2025 at 2:15 PM
Reposted by EstaM
CDiff going to or coming from the dogs? (and cats)
🤔73yo recur Cdiff Rx'd with Van, Fidax, FMT, bezlotoxumab
👍Dogs + for Cdiff, dogs placed, no more Cdiff
🤔Studies have shown cats and dogs can harbor CDiff
🤔Consider in tough cases
(With apologies to dog/cat owners)
#GIsky #IMsky #Medsky
🤔73yo recur Cdiff Rx'd with Van, Fidax, FMT, bezlotoxumab
👍Dogs + for Cdiff, dogs placed, no more Cdiff
🤔Studies have shown cats and dogs can harbor CDiff
🤔Consider in tough cases
(With apologies to dog/cat owners)
#GIsky #IMsky #Medsky
December 14, 2025 at 2:06 PM
Reposted by EstaM
when I use etomidate, I generally add fentanyl (analgesia) & midaz (prolongs sedation >5 min & reduces risk of awareness)
I wonder what the BP difference is between ketamine vs an etomidate-midaz-fent cocktail?? 🤔
my guess would be: not much
don’t use pain as a pressor
I wonder what the BP difference is between ketamine vs an etomidate-midaz-fent cocktail?? 🤔
my guess would be: not much
don’t use pain as a pressor
December 11, 2025 at 11:13 PM
when I use etomidate, I generally add fentanyl (analgesia) & midaz (prolongs sedation >5 min & reduces risk of awareness)
I wonder what the BP difference is between ketamine vs an etomidate-midaz-fent cocktail?? 🤔
my guess would be: not much
don’t use pain as a pressor
I wonder what the BP difference is between ketamine vs an etomidate-midaz-fent cocktail?? 🤔
my guess would be: not much
don’t use pain as a pressor
Reposted by EstaM
🔥Fresh blog🔥 Hot take on RSI trial of ketamine vs etomidate
RSI & EvK trials both show *more* BP instability with ketamine *but* lower mortality with ketamine 🤔
Cause of BP drops with ketamine?
- Less pressor pre-intubation?
- Ketamine provides analgesia (eliminating pain-as-a-pressor)?
... #1/2
RSI & EvK trials both show *more* BP instability with ketamine *but* lower mortality with ketamine 🤔
Cause of BP drops with ketamine?
- Less pressor pre-intubation?
- Ketamine provides analgesia (eliminating pain-as-a-pressor)?
... #1/2
December 10, 2025 at 4:00 PM
🔥Fresh blog🔥 Hot take on RSI trial of ketamine vs etomidate
RSI & EvK trials both show *more* BP instability with ketamine *but* lower mortality with ketamine 🤔
Cause of BP drops with ketamine?
- Less pressor pre-intubation?
- Ketamine provides analgesia (eliminating pain-as-a-pressor)?
... #1/2
RSI & EvK trials both show *more* BP instability with ketamine *but* lower mortality with ketamine 🤔
Cause of BP drops with ketamine?
- Less pressor pre-intubation?
- Ketamine provides analgesia (eliminating pain-as-a-pressor)?
... #1/2
Reposted by EstaM
My name is Paul and I am a coffee addict
🤔Review suggesting regular consumption reduces progression of liver disease, slowing progression to cirrhosis and HCC. (also reviews mechanisms)
👍Of benefit in pts with ALD, Viral hep, MASLD, and Cirrhosis
😀Can I have another cup??
#GIsky #IMSky #medsky
🤔Review suggesting regular consumption reduces progression of liver disease, slowing progression to cirrhosis and HCC. (also reviews mechanisms)
👍Of benefit in pts with ALD, Viral hep, MASLD, and Cirrhosis
😀Can I have another cup??
#GIsky #IMSky #medsky
December 7, 2025 at 2:23 PM
Reposted by EstaM
The saga continues: Resmetirom for MASH
🤔1 yr extension Maestro-NAFLD ( Medscape, presented at ACG scientific meeting)
👍Child A MASH at 1 year res of clinically sig portal hypertension in 20%, year 2 28%
👍50% with 25% ⬇️ liver stiff
👍35% from F4 to F3
Not too shabby
#GISky #IMsky #MedSky
🤔1 yr extension Maestro-NAFLD ( Medscape, presented at ACG scientific meeting)
👍Child A MASH at 1 year res of clinically sig portal hypertension in 20%, year 2 28%
👍50% with 25% ⬇️ liver stiff
👍35% from F4 to F3
Not too shabby
#GISky #IMsky #MedSky
December 5, 2025 at 7:48 PM
Reposted by EstaM
this article is so unserious it feels satirical
whole-body MRI scans for worried well are horrifically low-value
they find incidentalomas, leading to downstream costs & iatrogenic harm
not sure what it's doing in a newspaper (if that's what we're calling the WaPo)
www.yahoo.com/lifestyle/ar...
whole-body MRI scans for worried well are horrifically low-value
they find incidentalomas, leading to downstream costs & iatrogenic harm
not sure what it's doing in a newspaper (if that's what we're calling the WaPo)
www.yahoo.com/lifestyle/ar...
December 5, 2025 at 10:17 PM
this article is so unserious it feels satirical
whole-body MRI scans for worried well are horrifically low-value
they find incidentalomas, leading to downstream costs & iatrogenic harm
not sure what it's doing in a newspaper (if that's what we're calling the WaPo)
www.yahoo.com/lifestyle/ar...
whole-body MRI scans for worried well are horrifically low-value
they find incidentalomas, leading to downstream costs & iatrogenic harm
not sure what it's doing in a newspaper (if that's what we're calling the WaPo)
www.yahoo.com/lifestyle/ar...
Reposted by EstaM
Prasad just got a 95% BSA 3rd degree burn in the NEJM 🍿
December 4, 2025 at 2:06 AM
Prasad just got a 95% BSA 3rd degree burn in the NEJM 🍿
Reposted by EstaM
treatment of severe/refractory hypoglycemia (IBCC update)
commonly messed up in practice & literature 🤦♂️
key points:
🧃 IV dextrose gtts are good but not super effective
🧃 PO carbs are more effective
🧃 IV steroid for refractory dz
🧃 structured escalation
🧃 rarely needs ICU admit #EMIMCC
commonly messed up in practice & literature 🤦♂️
key points:
🧃 IV dextrose gtts are good but not super effective
🧃 PO carbs are more effective
🧃 IV steroid for refractory dz
🧃 structured escalation
🧃 rarely needs ICU admit #EMIMCC
November 30, 2025 at 5:18 PM
treatment of severe/refractory hypoglycemia (IBCC update)
commonly messed up in practice & literature 🤦♂️
key points:
🧃 IV dextrose gtts are good but not super effective
🧃 PO carbs are more effective
🧃 IV steroid for refractory dz
🧃 structured escalation
🧃 rarely needs ICU admit #EMIMCC
commonly messed up in practice & literature 🤦♂️
key points:
🧃 IV dextrose gtts are good but not super effective
🧃 PO carbs are more effective
🧃 IV steroid for refractory dz
🧃 structured escalation
🧃 rarely needs ICU admit #EMIMCC
Reposted by EstaM
Prasad spent the pandemic braying about EBM & the "need" for RCTs to show that masks work
Now he's changing FDA policy based on a few old VAERS reports of dubious veracity
This is unhinged
(And anyone who actually cared about saving kids' lives would focus on measles & pertussis vax rates)
Now he's changing FDA policy based on a few old VAERS reports of dubious veracity
This is unhinged
(And anyone who actually cared about saving kids' lives would focus on measles & pertussis vax rates)
After you read the Prasad memo, read this.
Covid-19 vaccines protect children from severe disease. Here is the evidence
“Over and over again, Covid-19 has shown it can cause severe disease in children, disease that is preventable by a safe and effective vaccine,” writes former CDC Director Rochelle Walensky.
www.statnews.com
November 30, 2025 at 10:25 PM
Prasad spent the pandemic braying about EBM & the "need" for RCTs to show that masks work
Now he's changing FDA policy based on a few old VAERS reports of dubious veracity
This is unhinged
(And anyone who actually cared about saving kids' lives would focus on measles & pertussis vax rates)
Now he's changing FDA policy based on a few old VAERS reports of dubious veracity
This is unhinged
(And anyone who actually cared about saving kids' lives would focus on measles & pertussis vax rates)
Reposted by EstaM
updated IBCC chapter on severe influenza
most notable updates are on the pharmacology of newer antivirals (peramavir & baloxavir)
oseltamavir remains 1st line for patients without contraindications
(yeap, data on these isn't great, but we're stuck with them)
emcrit.org/ibcc/influen... #EMIMCC
most notable updates are on the pharmacology of newer antivirals (peramavir & baloxavir)
oseltamavir remains 1st line for patients without contraindications
(yeap, data on these isn't great, but we're stuck with them)
emcrit.org/ibcc/influen... #EMIMCC
November 29, 2025 at 3:36 PM
updated IBCC chapter on severe influenza
most notable updates are on the pharmacology of newer antivirals (peramavir & baloxavir)
oseltamavir remains 1st line for patients without contraindications
(yeap, data on these isn't great, but we're stuck with them)
emcrit.org/ibcc/influen... #EMIMCC
most notable updates are on the pharmacology of newer antivirals (peramavir & baloxavir)
oseltamavir remains 1st line for patients without contraindications
(yeap, data on these isn't great, but we're stuck with them)
emcrit.org/ibcc/influen... #EMIMCC
Reposted by EstaM
The truth and nothing but the truth...PEth
🤔Phosphatidylethanol (PEth) detects ETOH exposure up to 12 days after a binge, up to 4 weeks with heavy use
🤔Reported ETOH consumption may not be accurate
🤔Useful to help sort out MASLD; MetALD, ALD
See flow sheets below
#IMsky #GIsky #Medsky
🤔Phosphatidylethanol (PEth) detects ETOH exposure up to 12 days after a binge, up to 4 weeks with heavy use
🤔Reported ETOH consumption may not be accurate
🤔Useful to help sort out MASLD; MetALD, ALD
See flow sheets below
#IMsky #GIsky #Medsky
November 28, 2025 at 7:21 PM
Reposted by EstaM
Patient with cirrhosis and INR of 3 needs a procedure
Please step away from the FFP
EVERY guideline & article agrees that FFP shouldn't be given for pre-procedure coag optimization (even high-risk procedures)
Plt & fibrinogen are more controversial
Discussion emcrit.org/ibcc/cirrhos... #EMIMCC
Please step away from the FFP
EVERY guideline & article agrees that FFP shouldn't be given for pre-procedure coag optimization (even high-risk procedures)
Plt & fibrinogen are more controversial
Discussion emcrit.org/ibcc/cirrhos... #EMIMCC
November 27, 2025 at 1:06 PM
Patient with cirrhosis and INR of 3 needs a procedure
Please step away from the FFP
EVERY guideline & article agrees that FFP shouldn't be given for pre-procedure coag optimization (even high-risk procedures)
Plt & fibrinogen are more controversial
Discussion emcrit.org/ibcc/cirrhos... #EMIMCC
Please step away from the FFP
EVERY guideline & article agrees that FFP shouldn't be given for pre-procedure coag optimization (even high-risk procedures)
Plt & fibrinogen are more controversial
Discussion emcrit.org/ibcc/cirrhos... #EMIMCC
Reposted by EstaM
updated the acute liver failure chapter
biggest change is increasing support for early CRRT to remove NH3 (to reduce elevated intracranial pressure)
now rec'd for clinically overt encephalopathy (Grade 2-4)
if admitting to ICU for ALF & encephalopathy, just dialyze
emcrit.org/ibcc/alf/ #EMIMCC
biggest change is increasing support for early CRRT to remove NH3 (to reduce elevated intracranial pressure)
now rec'd for clinically overt encephalopathy (Grade 2-4)
if admitting to ICU for ALF & encephalopathy, just dialyze
emcrit.org/ibcc/alf/ #EMIMCC
November 28, 2025 at 1:51 PM
updated the acute liver failure chapter
biggest change is increasing support for early CRRT to remove NH3 (to reduce elevated intracranial pressure)
now rec'd for clinically overt encephalopathy (Grade 2-4)
if admitting to ICU for ALF & encephalopathy, just dialyze
emcrit.org/ibcc/alf/ #EMIMCC
biggest change is increasing support for early CRRT to remove NH3 (to reduce elevated intracranial pressure)
now rec'd for clinically overt encephalopathy (Grade 2-4)
if admitting to ICU for ALF & encephalopathy, just dialyze
emcrit.org/ibcc/alf/ #EMIMCC