"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/

𝐂𝐂𝐑 𝐁𝐥𝐨𝐠 - 𝐓𝐡𝐞 𝐄𝐭𝐨𝐦𝐢𝐝𝐚𝐭𝐞 𝐂𝐨𝐧𝐮𝐧𝐝𝐫𝐮𝐦

Induction for rapid sequence intubation in the critically ill often feels like the swing of a pendulum.

What's your take on the etomidate - ketamine dichotomy?

Here's ours.

➡️ https://criticalcarereviews.com/blog/current

ICU #POCUS "Secrets":

This is why some times we achieve perfect alignment of the cardiac probe with the interventricular septum (IVS) & record great 4-chamber clips and other times* we cannot even find the IVS (when there is AIR interposed between the heart apex and the probe):

Pelvic Binders Logistics
Key: Indiscriminate application in significant blunt trauma w/ any HD instability
Don’t “rock the pelvis” - dislodges clots, increases bleeding + pain
Logistics: place binder on gurney + transfer pt directly from EMS stretcher onto binder

youtube.com/shorts/YaWUP...
#EMIMCC

💯. Also would add that CIWA is only useful for a patient w/ alcohol withdrawal and NO other active medical/neuro issues that could cloud the picture.

I don’t know where such simple one-issue patients are. Nearly all ICU patients in 2025 have several active problems. So we dont use CIWA #EMIMCC

Wow 😳

Compression-only CPR is good for VT/VF arrest, b/c the lungs & blood have some O2 in them.

In opioid-induced cardiac arrest, lung/blood O2 is *gone* by the time arrest occurs. So probably need assisted ventilation along w/ compressions. Pushing around deoxygenated blood doesn't work. #EMIMCC

CDC is investigating a multi-state (4 states) Paraburkholderia fungorum outbreak tied to ultrasound gels

#POCUS #foamed #foamcc #meded #Medsky #idsky #emimcc

You intubate a patient smoothly with roc & ketamine

After connection with the vent:
- oxygen saturation is 98%
- etCO2 tracing & values are normal
- breath sounds are symmetric

the vent starts alarming for a 60% air leak

you ascultate the neck & cannot hear a leak

what is happening? #1/2 #EMIMCC

Does the over rapid correction of hypernatraemia really cause cerebral oedema in adults❓

Most guidelines suggest a rate of correction < 10mmol/L per day, and whilst there is evidence of risk in children (with tighter, more vulnerable brains) the evidence of risk in adults is scant

1/

The upside of defining contrast nephropathy in this way is it becomes very easy to measure the incidence of AKI. In 6 recent well done studies, the incidence runs from 1 to 11% among patients with CKD.

A BP of 150/100 in an asymptomatic patient does not need referral to the ED.

Please. 🙏

Sometimes weird things happen. Patient in the trauma bay. C spine injury. Multiple rib fractures on the left.

Despite that, develops left lung collapse and white out.

An older but very functional patient presented from another facility to the neuro ICU with a brain abscess after a dental procedure.

The abscess was being treated conservatively and was improving.

Pulm was consulted for hypoxia.

#emimcc

Never underestimate the damage an innocuous looking stab injury can do. It's often far worse than it appears externally.

ECG of a middle-aged gentleman after blunt trauma to the chest.

What's happening here?

Last night shift in the trauma red area -

1. Electrocution leading to rhabdomyolysis.

2. Massive hemothorax.

3. Massive IC bleed with herniation.

4. Cardiac tamponade that ultimately lead to an ED thoracotomy.

5. Flail chest.

And that's just half of it. This job is never boring.

Pollution over Delhi has reached insane levels. Visible smog over our hospital. Many finding it difficult to stay long outdoors.

It's a nightmare.