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Alex Koyfman @emhighak.bsky.social · 21/02/2026

Have successfully managed many of these pts. NIPPV is really 1a and NTG 1b. Have never really understood really high doses of NTG; have seen resultant hypotension and other extraneous cognitive load. Also data not robust for improving meaningful outcomes. #emimcc

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Zahir @numosemed.bsky.social · 07/01/2026

Really excited to publish in @emdocs about FOAM Cortex (foamcortex.com). FOAMed resources like emDocs are amazing—our goal is to help get that knowledge to the bedside faster. #FOAMed hashtag#MedEd. www.emdocs.net/foam-cortex-... @emhighak.bsky.social

emdocs.net

FOAM Cortex: A New Way to Access FOAMed Knowledge at the Point of Care - emDocs

A new frontier for FOAMed.

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josh farkas 💊 @pulmcrit.bsky.social · 18/11/2025

Contrast may cause anaphylacTOID reactions (not anaphyLAXIS) (anaphylactoid rxns = angry mast cells spit out histamine; usually less severe than anaphylaxis) Canadian guidelines: don't pre-treatment w/ steroid, give antihistamine This makes physiological sense! Thank you science! #1/3. #EMIMCC

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Alex Koyfman @emhighak.bsky.social · 24/10/2025

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

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Alex Koyfman @emhighak.bsky.social · 19/10/2025

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

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josh farkas 💊 @pulmcrit.bsky.social · 19/10/2025

#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).

media.tenor.com

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 '' .

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josh farkas 💊 @pulmcrit.bsky.social · 19/10/2025

#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

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a group of surgeons are dancing in an operating room with the words happy surgery team great results

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josh farkas 💊 @pulmcrit.bsky.social · 08/10/2025

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

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Sad Sad Bean GIF

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Alex Koyfman @emhighak.bsky.social · 29/09/2025

Crucial to learn from all fields of medicine in order to provide thoughtful, comprehensive care for the pts in front of us #emimcc

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josh farkas 💊 @pulmcrit.bsky.social · 25/09/2025

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...

jamanetwork.com

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...

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Alex Koyfman @emhighak.bsky.social · 22/09/2025

1 more point that will sharpen your clinical gestalt and decision making. Details matter, particularly in EM. #emimcc

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josh farkas 💊 @pulmcrit.bsky.social · 14/09/2025

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

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

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Alex Koyfman @emhighak.bsky.social · 05/09/2025

Spectrum of disease w nuanced management. Hard to flesh out.

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Alex Koyfman @emhighak.bsky.social · 02/09/2025

Quite thoughtful on your end @pulmcrit.bsky.social. Something that would definitely benefit from standardization and benefit critically ill pts.

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Skyler Lentz @skylerlentz.bsky.social · 10/08/2025

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/...

jacc.org

Continuum of Preshock to Classic Cardiogenic Shock in the Critical Care Cardiology Trials Network Registry:

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josh farkas 💊 @pulmcrit.bsky.social · 06/08/2025

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.

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a person is holding a red flag in a field .

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josh farkas 💊 @pulmcrit.bsky.social · 30/07/2025

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

emcrit.org

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 […]

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Anand Swaminathan @emswami.bsky.social · 10/07/2025

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

youtube.com

The Cognitive Pause: Refractory Hypotension #criticalcare #emergencymedicine

YouTube video by EMSwami

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josh farkas 💊 @pulmcrit.bsky.social · 29/05/2025

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)

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two women are sitting next to each other and one is pointing at the camera

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Alex Koyfman @emhighak.bsky.social · 27/03/2025

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

amazon.com

Emergency Medicine Thinker

Emergency Medicine Thinker: 9781009379915: Medicine & Health Science Books @ Amazon.com

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josh farkas 💊 @pulmcrit.bsky.social · 15/03/2025

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: emcrit.org/pulmcrit/michelin-chest-…

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Alex Koyfman @emhighak.bsky.social · 17/02/2025

Very interested to hear what folks think of this for EM: www.acgme.org/globalassets... #medsky #emimcc

acgme.org

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josh farkas 💊 @pulmcrit.bsky.social · 11/02/2025

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

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josh farkas 💊 @pulmcrit.bsky.social · 29/01/2025

common error: we decide to perform procedures based on the *absolute* risk, not the risk/benefit *ratio* for example: 1) unnecessary procedure is done on a healthy patient 2) necessary procedure isn't done on a high-risk patient #EMIMCC

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a cartoon drawing of a scale with eyes on it

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josh farkas 💊 @pulmcrit.bsky.social · 27/01/2025

milrinone pharmacology drives me crazy half-life is ~2 hrs (longer in renal dysfunction, which our patients often have) without a bolus, levels won't hit steady state for >4 hr how does it make mathematical sense to give this drug without a bolus in an acutely sick patient? 🧵#1/2

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Alex Koyfman @emhighak.bsky.social · 23/01/2025

“Our shared humanity is more important than any political disagreement or cultural divide.” -Bill Clinton, Citizen #medsky #emimcc

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Alex Koyfman @emhighak.bsky.social · 09/01/2025

Success is rarely linear; it’s often the sum of detours, setbacks, and unexpected turns. -BMezrich

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Alex Koyfman @emhighak.bsky.social · 09/01/2025

A star wants to see themselves rise to the top. A leader wants to see those around them rise to the top. -SSinek

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Alex Koyfman @emhighak.bsky.social · 09/01/2025

Working hard for something we don’t care about is called stress; working hard for something we love is called passion. -SSinek

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Alex Koyfman @emhighak.bsky.social · 09/01/2025

Speak when you are angry and you will make the best speech you will ever regret. -Ambrose Bierce

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Alex Koyfman @emhighak.bsky.social · 05/01/2025

Top mixture of 2024 emdocs.net posts: www.emdocs.net/top-emdocs-p... #emimcc #medsky

emdocs.net

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josh farkas 💊 @pulmcrit.bsky.social · 02/01/2025

disagree with this “triangle of saftey” nonsense in morbid obesity or cardiomegaly, this location could be dangerous (eg, diaphragm can be really high) so POCUS is key to establish anatomy before tube insertion (and incidentally, ICU patients never look like this in real life 🙄) #EMIMCC

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Alex Koyfman @emhighak.bsky.social · 20/12/2024

Focused ultrasound should replace many aspects of our current physical exam. #emimcc #medsky

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Alex Koyfman @emhighak.bsky.social · 20/12/2024

Mastery of clinical care is the purest form of patient and social advocacy in our field. #emimcc #medsky

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Alex Koyfman @emhighak.bsky.social · 20/12/2024

Beware negative inotropy for rate control in patient with subtle cardiogenic shock. #medsky #emimcc

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josh farkas 💊 @pulmcrit.bsky.social · 17/12/2024

the key clue here is the neutrophil/lymphocyte ratio is 101! that's super high and *way* above what would be expected in DKA without an underlying infection (usually below ~15ish) for context, NLR >15 is in a range consistent with septic shock 🧵 4/5 pubmed.ncbi.nlm.nih.gov/35071771/

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Alex Koyfman @emhighak.bsky.social · 13/12/2024

Check out the latest posts: www.emdocs.net. Fantastic variety of our much-needed field. #medsky #emimcc

emdocs.net

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