Discover and read the best of Twitter Threads about #CriticalCare

Most recents (23)

Floating the big yellow bird today. (#swanganz #SCG #PAC). Always remember to “lift it, flick it, flush it” and watch the results on the monitor before you set it a sail to make sure you’re on the right channel and you’re scale is correct. #zentensivist @doc_BLocke
Irony is I get flask for not doing bronchs where I rarely find anything and I get flak for doing Swans where, as in this case, I often find useful things
To elaborate on “lift it flick it flush it” just in case it’s not obvious: b/f you float the swan, check it’s response on the monitor: lift it (the tip) 10 cm & see if baseline rises accordingly on the monitor; flick the tip to see if you get deflections; then flush it to see if
Read 6 tweets

Welcome to the second installation in our CASE report series! We are sharing challenging, interesting, and teachable cases from our resident teams here at CWRU! Chief Resident @Keithr3890 brings the second case from his time in our Medical ICU #MedEd #Tweetorial #CriticalCare

HPI: A 34 yo F is brought to an outside hospital ED by her husband with 3 days of worsening abdominal pain and new onset confusion. Triage VS: T 35.0, HR 128, BP 50/28, RR 20, SpO2 78% on RA.

The patient is quickly identified as having severe, undifferentiated circulatory shock. Which of the four ‘buckets’ of circulatory shock is most likely in this patient based on pre-test probability?
Read 20 tweets
A #MedEd Thread for #pulm #criticalcare #applicants. How do you pick a program? What questions do you ask in a fellowship #interview? Here are some ways programs differ and tagged @IUPCCM experts to answer any questions you may have! #MedTwitter
#PAH: Does Pulm house pulmonary hypertension and manage vasodilator therapy? Or is this managed by a different department? Are there opportunities to learn this if so? @TimLahm @RFPMachado
#IP: Do you have experts performing advanced #bronchoscopy such as #navigational? Does Pulm place stents, valves? Is there #EBUS volume for general fellows to become proficient? How much of this is done by other departments such as Thoracics or ENT? @ChrisKniese
Read 13 tweets
How does a city's trauma system come together to both prepare for the expected surge of the #COVIDー19 #pandemic & manage the ongoing #epidemic of #gunviolence & other trauma?

Through a great collaborative effort, we published the #Philadelphia experience in @JTraumAcuteSurg

The full paper is published ahead of print here:…

It represents the importance of #teamwork in ensuring a robust, rapid, coordinated effort to manage an evolving threat

Our publication timing coincides with a brutal #July4th weekend where #Philadelphia saw over 30 people shot including several children

But how did the #pandemic and #socialdistancing mandate affect trauma volume in our centers?
Read 15 tweets
Congratulations to the #YalePCCSM physicians who were honored in @connecticutmag 2020 Top Docs Issue! #YaleMed #YNHH
Richard A. Matthay, MD #CriticalCare #PulmonaryMedicine Image
Carolyn L. Rochester, MD, FCCP #CriticalCare #PulmonaryMedicine Image
Read 12 tweets
#CHEST bronchoscopy guidelines fir #COVID19 patients. The 6 statements in a thread .. #MedEd #FOAMed #MedTwitter #StaySafeForScience #EBM #CriticalCare…
1-Use full #PPE and #n95Masks with confirmed and suspected #COVID19 cases undergoing #bronch.
2-Check nasopharyngeal swab test for #COVID19 first, if more deep samples are indicated, bronch + BAL can be performed.
3-Use #n95Masks during #bronchoscopy procedures to asymptomatic patients in areas with #COVID19 community spread.
4-Test patients for #COVID19 prior to #bronchoscopy in areas with community spread.
Read 5 tweets
1). “Freedom is a road seldom traveled by the multitude”— Renaldo Williams started his #chieftalk this morning @VUMCSurgRes with this Frederick Douglass quote— and took us down several personal roads in an incredibly thoughtful and moving #grandrounds. Thread follows....
2). It was about roads— the many different types of roads that get us from one place to another— some unmarked, some treacherous, some worn, some patched. And he reflected on his road— from Holmes County #Mississippi where 45% live in poverty.
3). To successfully navigate any road, you need a map and a compass (value systems), rest stops (opportunities that open doors), and guides (mentors).
Read 10 tweets
1/n Some nuances with #COVID19 #criticalcare. They are the exception
👉🏼Permissive Hypoxemia
😨BiPAP, HFNO, prone sleeping, control fever
👉🏼VT: 6mg/Kg IBW - ARMA
👉🏼Stent the lung: High PEEP table ARDSnet
👉🏼Prone: P/F <150 -PROSEVA
👉🏼Dry lungs: limit fluids, diurese - FACTT Image
👉🏼CAM-ICU: Pain, agitation, delirium assessment, minimize sedation, limit propofol (PRIS)
👉🏼Wake up and Breathe: SAT daily - ABC Trial, SBT PS 5/5
👉🏼Remove lines
👉🏼PUD prophylaxis
👉🏼DVT prophylaxis Image
3/n. If you haven’t seen this video from Dave Janz in New Orleans. It’s a good one on #criticalcare in #COVID19
Read 5 tweets
1/7 France has done the first pharmacokinetic (PK) study of HCQ for ICU patients of #COVID19, a fantastic job for dosage optimization.
🔸13 patients, average weight=82.7 kg
🔸46% pts BMI>30
🔸12 on mechanical ventilators
🔸1 on ECMO
🔸30.7% with medium/severe renal dysfunction
🔸2 pts had QT prolongations (>500ms ), but not related to HCQ levels.
🔸 Regimen D: 200mgX3/day for 7 days;
PK simulation shows HCQ reached the therapeutic level of 1mg/L on day 2.5 but exceeds 2mg/L (risk of ocular toxicity) on day 5
🔺In this D regimen, the average HCQ dose is ~7.5 mg/kg/day, which is above the well established safe upper limit: 6.5 mg/kg/day; meanwhile, the HCQ blood concentration exceeds the upper safe level: 2mg/L.
Read 7 tweets
🗂️THREAD: U.S./global #COVID19 clinical/research patient/healthcare worker registries seen on #medtwitter

Many specialty-society/focused registries launched in last few weeks, attempt to collect them here

List 👇🏽

2/n: @SCCM's VIRUS: Viral Infection and Respiratory Illness Universal Study @covid19registry

Inclusion criteria 👇🏽…

Find out if your site is already enrolled:…

#Pulmonology #Pulm #CriticalCare #PCCM
3/n: International #COVID19 Dermatology Registry led by @DrEstherFreeman @AADskin

Looking for:
1. #COVID19 pts who develop #skin findings
2. #dermatology pts who develop #COVID19

h/t @DrStevenTChen #dermtwitter
Read 11 tweets
(1/) I want to bounce around a disease model for #COVID19. This is hypothesis, some parts are hand-wavy, but I'd like to think a lot is also based on evidence. I'll try to clearly distinguish knowns from assumptions as we go...

#COVID2019 #SARSCoV2 #medtwitter #FOAMcc #FOAMed
(2/)First, whatever #COVID19 is, it doesn't sound like #ARDS. Physiology doesn't line up
1-Easy to vent, but hard to oxygenate. Normal lung compliance
2-Deteriorate rapidly
3-Responds to proning, PEEP, & prolonging I:E
4-Tendency to suddenly de-recruit…
Read 23 tweets

Hey #ICU #CriticalCare #QoL folks

Want to take a quick break from COVID19 research?

Here's a tour of the new @AnnalsATS I&P piece by me, Michael Hurley, @IanOppenheim, @DrMeganHoseyPhD, @AnnEkedahl
Recent systematic reviews of services & interventions to improve Quality of Life (QoL) for ICU survivors have been pretty dismal. So we decided to go back to the drawing board and review some fundamentals. #ICU
Definition 1:
@WHO defines QoL as:
“an individual’s perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns.”
Read 24 tweets
#COVIDー19 This is a ventilator. It is not intensive care. Intensive care is medical care delivered by trained and experienced staff. #weareintensivecare @WFPICCS @SvuhIcu @ICU_Ireland @PedsICU @COAIrl
#coronavirus ICU is staffing, trained in the application of tech and equipment. Supported by Laboratory Medicine, Anaesthesia, Radiology, Surgery, Medicine. @CcoHse @roinnslainte @McCormackCEO @mringster #muchmorethanaventilator @sleepypedsdoc @kfinmccarthy
#zeitgeist Intensive care is a team with actively engaged and experienced dieticians, physiotherapists and pharmacists. @DSemple5 @MoninneHowlett @SapnaKmd Everyone contributes to the care of the patient, every day. #weareintensivecare
Read 14 tweets
Pharmacy pearls I’ve noticed in ICU COVID patients... 1) ⬆️ triglycerides (from HLH features of these patients) make using propofol sedation regimens difficult, have had to use BZDs to achieve apparopriate sedation for paralysis... 1/
2) look for Co-infections. These patients can be persistently febrile but don’t let that fool you into thinking it’s due to COVID alone. Co-infections DO happen. Viral or bacterial. Trust me.... 2/
3) the need to keep patients net negative/even with diuresis/ ultrafiltration makes pts more sensitive to hypotension from propofol (when you can use it). 4) the drug interactions with Kaletra/plaquenil and other drugs makes me want to 😭..... 2/
Read 7 tweets
1/10 It’s hard to shut my mind off in the face of #COVID19. As #AcuteCareSurgeons our day/night/weekend jobs taking care of #injured patients and #patients needing #EmergencySurgery for abdominal and soft tissue diseases do not dissipate.
2/10 Yet we are also experts in #CriticalCare and need to prepare to care for patients w/ #respiratoryfailure and #shock due to #COVID19. We are implementing #plans based on the little evidence that exists while trying to stay #safe, #healthy, and #resilient.
3/10 We step into the trauma bay as others threaten to shoot our patient (but police can protect us). We do operations where rHepC/HIV risk is high (but PEP can protect us). We don't shy away from blood, feces or dead flesh up to our eyeballs (but we have #PPE to protect us).
Read 10 tweets
Els que em coneixeu sabeu que no sóc d’escriu-re gaire a les xarxes. Sóc infermera d’UCI, una de tantes, que aquests dies ens trobem en una situació mai vista abans. He decidit fer un tweet per explicar-vos algunes coses. Obro fil:
La nostra feina mai no ha estat reconeguda, tot i que som personal amb formació superior i un nivell d’especialització molt alt. Les condicions en que hem de treballar aquests últims dies ens porten al límit, doncs també som persones, i ens veiem afectades a tots els nivells.
Tinc companyes que aquests dies ( que just ara comencen) han decidit separar-se de les seves famílies per l’alt risc de contagi al que estem exposats com a professionals.
Read 10 tweets
Alright #medtwitter, #medstudenttwitter, & #CriticalCare, today’s #tweetorial is on the ever challenging and misinterpreted lactate!

So, what does lactate most appropriately represent?

If you’re like me, you had lactate = anaerobic respiration = hypoxia drilled into your head.

First, is this real? And then, most importantly, is this clinically relevant?

To unravel this mystery-we need to know where lactate comes from!

Lactate is made in the cytoplasm according to this reaction:…

Read 20 tweets
2/ PRVC = Continuous Mandatory Ventilation, Pressure Limited, Time Cycled with Adaptive Targeting.

SETTINGS: Tidal volume, Insp Time, Fio2, PEEP, RR

Breath to Breath feedback of exhaled TV, compared to target with adjustment of subsequent insp pressure to lead to steady TV

PRVC - Marquet Servo i
Autoflow - Drager
Adaptive Pressure Ventilation - Hamilton Galileo
Volume Control + - Puritan Bennett
Volume Targeted Pressure Control, Pressure Controlled Volume Guaranteed - Engstrom
Read 7 tweets
Wow, this is crazy! It’s amazing to see how much love my Avengers as pressors series has been getting 😁 The following is a thread with all 7 pressors for easy access!

Thanks for the idea @ETSshow!

#MedEd #pressors #criticalcare #medicaleducation #avengers
The first Avenger: Norepinephrine as Captain America, the typical first line pressor.

Epinephrine as Iron Man, always good in a crisis.

Read 10 tweets
I listen to ~90 #Podcasts on a (semi) regular basis. Let me give you a rundown of ALL of them and why you should listen to some amazing #FOAMed, especially for all the new #EmergencyMedicine interns. #FOAMed #MedEd #medtwitter
First of all, you need a good podcast app. I absolutely love Downcast. Great app, gives you more control over playback, downloading, and allows you to categorize your podcasts into playlists (picture 2). This is where you get to customize your #FOAMed experience! #medtwitter
In no particular order,

- Anesthesia and Critical Care Reviews and Commentary (ACCRAC). Great insight into Crit Care from an anesthesia perspective. Coming from EM, this is great to listen to- much different from my day-to-day! #FOAMed #FOAMcc #CriticalCare
Read 88 tweets
1/ Why is lactate elevated in sepsis or septic shock?

@dolan_russell & I explore this common #ICU pimp question via #tweetorial.

We're taught that ↓O2 revs up anaerobic metabolism causing ↑ lactate. But wait, there's more...

#medtwitter #FOAMed #meded #FOAMcc #criticalcare
2/ In homeostasis, lactate is continually produced and metabolized; serum concentration is at steady state.

Which of the following organs is responsible for the majority lactate consumption and metabolism?
3/ The liver is responsible for ~70% of lactate metabolism.

Patients with hepatic dysfunction can have ↑ lactate 2/2 ↓ clearance or ↑ production. Also, cirrhotics are more prone to hyperlactatemia in setting of sepsis.

Diving deeper, how does the liver metabolize lactate?
Read 13 tweets
The ANDROMEDA- SHOCK Randomised Clinical Trial
Thoughts by @z_cepillo…
Multicentre (28) open label RCT to determine if peripheral perfusion targeted resuscitation during early septic shock in adults is more effective than a lactate-targeted resuscitation for reducing mortality.
Inclusion criteria: adult patients with septic shock (infection, lactate >2, vasopressors to maintain MAP >65mmHg after IV fluid of 20ml/kg over 60 mins.
Read 26 tweets
#Tweetorial on hypoxemic #respiratoryfailure. #FITSurvivalGuide #FOAMed
1️⃣ Shunt
2️⃣ V/Q mismatch
3️⃣ Low FiO2/low O2 tension
4️⃣ Alveolar hypoventilation
5️⃣ Diffusion limitation
6️⃣ Venous admixture
1️⃣Shunt - can be intra or extrapulmonary. No V, only Q. Does not respond to O2 - shunt fraction not exposed to o2. Inflamm alveolar dz (eg PNA) can p/w shunt (imp. vasoconstr.) Think abt PFO w R➡️L shunt in PE, ARDS (elevation in R sided pressures), check bubble study. Aa grad ⬆️
2️⃣V/Q mismatch. More Q than V but regions with low V not entirely excluded from gas exchange. Can improve w increasing FiO2. Probably 75-90% of hypoxemia cases. Wide Aa gradient.
Read 7 tweets

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