Discover and read the best of Twitter Threads about #CriticalCare
Most recents (24)
What is #Pre-Hospital #CriticalCare? A short 🧵:
Also referred to as Pre Hospital Emergency Medicine (PHEM), #PHEM is “that area of medical care required for seriously ill or injured patients before they reach hospital (on-scene) or during emergency transfer to hospital” 1/11
Also referred to as Pre Hospital Emergency Medicine (PHEM), #PHEM is “that area of medical care required for seriously ill or injured patients before they reach hospital (on-scene) or during emergency transfer to hospital” 1/11
PHEM in Ireland is practiced by a small number of doctors who respond voluntarily to taskings from @AmbulanceNAS to serious illness or injury.
These doctors are supported by charities like @WicklowRR.
Other groups include: @WestCorkRR @EastCorkRR and @CRITICALcharity 2/11
These doctors are supported by charities like @WicklowRR.
Other groups include: @WestCorkRR @EastCorkRR and @CRITICALcharity 2/11
PHEM doctors complement the work of @PHECC practitioners in @AmbulanceNAS @DubFireBrigade and many other emergency agencies.
PHEM doctors can provide additional interventions, medications and decision-making, or simply be the closest resource to a time critical emergency. 3/11
PHEM doctors can provide additional interventions, medications and decision-making, or simply be the closest resource to a time critical emergency. 3/11
PICC line 🧵 #medicine
1/
A central device (i.e in the SVC) placed via a peripheral venous access
.
#irad #vascular #MedTwitter #FOAMed #hematology #Tweetorials @nihardesai7 @MedTweetorials #Cardiology #MedEd #oncology #internalmedicine @BrownJHM #MedStudentTwitter #cardiotwitter
1/
A central device (i.e in the SVC) placed via a peripheral venous access
.
#irad #vascular #MedTwitter #FOAMed #hematology #Tweetorials @nihardesai7 @MedTweetorials #Cardiology #MedEd #oncology #internalmedicine @BrownJHM #MedStudentTwitter #cardiotwitter
2/
Classically placed in the arm
May be placed in the leg (eg in #pediatrics /neonates – which may then terminate in the infrarenal IVC/iliacs)
.
#criticalcare #cardiovascular
Classically placed in the arm
May be placed in the leg (eg in #pediatrics /neonates – which may then terminate in the infrarenal IVC/iliacs)
.
#criticalcare #cardiovascular
3/
Advantages:
- Lower infection rate then central lines
- Used in the outpatient setting
- Can be used for several weeks to months
- Duration of PICC lines may be from 4 weeks to 6 months
(although they have been known to be functional for more than 300 days)
Advantages:
- Lower infection rate then central lines
- Used in the outpatient setting
- Can be used for several weeks to months
- Duration of PICC lines may be from 4 weeks to 6 months
(although they have been known to be functional for more than 300 days)
📢 Tweetorial on sepsis -endotoxin- cytokine cascade
👉Pathogen invasion in body
👉Pathogen expresses certain molecular patterns or
endotoxins called pathogen-associated molecular patterns (PAMPs)
👉
PAMPs are recognized by toll-like receptors expressed by
neutrophils
👉Pathogen invasion in body
👉Pathogen expresses certain molecular patterns or
endotoxins called pathogen-associated molecular patterns (PAMPs)
👉
PAMPs are recognized by toll-like receptors expressed by
neutrophils
👉 Activation of innate immunity and leukocytes
👉Release of cytokines - pro +
anti-inflammatory(interleukins 1, 6, 8, 10 &
tumor necrosis factor)
👉 Dysregulated host
response to infection - organ failures
👉 Immunoparalysis, reinfection,
hospital-acquired infections
👉Release of cytokines - pro +
anti-inflammatory(interleukins 1, 6, 8, 10 &
tumor necrosis factor)
👉 Dysregulated host
response to infection - organ failures
👉 Immunoparalysis, reinfection,
hospital-acquired infections
Futher in the thread , extracorporeal therapies targeted at each level of sepsis cascade would be discussed 👇
nejm.org/doi/full/10.10…
ncbi.nlm.nih.gov/pmc/articles/P…
nejm.org/doi/full/10.10…
ncbi.nlm.nih.gov/pmc/articles/P…
Drug of choice for ANAPHYLAXIS in a patient with no response to Epinephrine?
Patient is on Propranolol 60 mg BD for essential tremors.
#MedTwitter #emergencymedicine #CriticalCare
Patient is on Propranolol 60 mg BD for essential tremors.
#MedTwitter #emergencymedicine #CriticalCare
Which drug should be given?
#MedTwitter #MedEd #MedicalStudentTwitter #IMGs #IMG #medicaleducation #medicalinternship #medicineresidency #internalmedicine #doctors #madaktari #Medicos #medicina #médecins #Medizin #Likitoci #medicine #medical #FOAMed #FOAMim #FOAM4GP
#MedTwitter #MedEd #MedicalStudentTwitter #IMGs #IMG #medicaleducation #medicalinternship #medicineresidency #internalmedicine #doctors #madaktari #Medicos #medicina #médecins #Medizin #Likitoci #medicine #medical #FOAMed #FOAMim #FOAM4GP
Anaphylaxis is a severe, life threatening systemic hypersensitivity reaction characterized by being rapid in onset with potentially life threatening airway, breathing, or circulatory problems and is usually, although not always, associated with skin and mucosal changes.( ICD-11)
🫁 Physics of lung US 🫁
#lungultrasound
#ICU #CriticalCare #IntensiveCare #IntensiveCarecommunity #FOAM #JCardenas_MD #MICU #CICU @JCardenas_MD
#lungultrasound
#ICU #CriticalCare #IntensiveCare #IntensiveCarecommunity #FOAM #JCardenas_MD #MICU #CICU @JCardenas_MD
1️⃣(Left) Ultrasound waves reflected at the pleural line creating A-line reverberation artifacts.🫁
#lungultrasound
#ICU #CriticalCare #IntensiveCare #IntensiveCarecommunity #FOAM #JCardenas_MD #MICU #CICU @JCardenas_MD
#lungultrasound
#ICU #CriticalCare #IntensiveCare #IntensiveCarecommunity #FOAM #JCardenas_MD #MICU #CICU @JCardenas_MD
2️⃣(Center) As the interstitium thickens, the artifact pattern changes, with B-line artifacts obliterating A-lines. B-lines are hyperechoic vertical artifacts arising from the pleural line extending to the bottom of the field of view. 🫁
#lungultrasound
#lungultrasound
I went to med school to be a medical geneticist (went off piste) but always been fascinated by it. One way the environment interacts with our genome is through methylation - the addition of methyl groups to certain points in the dna string
This physical/chemical manipulation changes how the dna string folds and how easy it is for transcription machinery to access it. We have the same genome as ourselves as an egg, but clearly have organs and limbs now - methylation helped the egg produce these changes
An ENT surgeon friend sent me this epigenetic study on Japanese centenarians - they show less age related methylation at expected genes such as cancer and neuropsychiatric but the surprise was they are undermethylated for anti inflammatory genes eg TGFb
The specialty of #CriticalCare has achieved important advances in survival for many patients with the most complex disorders. Along with these advances, however, there has been an increasing awareness of the complicated and persistent morbidity that follows critical illness. 1/10
Episodes of critical illness result in multidimensional acquired or exacerbated conditions that may persist for years after the critical illness and may not be wholly reversible. Health inequities may worsen these outcomes. 2/10
A continuum of care for patients and families after critical illness, extending from the ICU to community or primary care, must become the standard of care and be developed concurrently with basic science inquiry to elucidate the multiple mechanisms of morbidity. 3/10
🧠 Intracranial pressure (ICP): current perspectives on physiology and monitoring 🧠 #FOAMcc #NeuroCritCare #FOAMed #EMCCM #NeuroICU #NeruroMonitoring #IntensiveCare #CriticalCare #MedEd 📖 Intensive Care Med (2022) 48:1471–1481
📖 doi.org/10.1007/s00134…
📖 doi.org/10.1007/s00134…
✅ ICP monitoring is now viewed as integral to the clinical care of many life-threatening brain insults, such as severe traumatic brain injury, subarachnoid hemorrhage, and malignant stroke.
#FOAMcc #NeurocritCare
#FOAMcc #NeurocritCare
✅ It serves to warn of expanding intracranial mass lesions, to prevent or treat herniation events as well as pressure elevation which impedes nutrient delivery to the brain. #FOAMcc #NeuroCritCare
“Ten tips to optimize #vasopressors use in the critically ill patient with #hypotension.” #IntensiveCare #MedTwitter #CardioTwitter #sepsis #FOAMed #FOAMcc #CriticalCare #EmergencyMedicine #PedsICU #ICU #EMCCM
📚 Intensive Care Med (2022) 48:736–739 rdcu.be/c57Se
📚 Intensive Care Med (2022) 48:736–739 rdcu.be/c57Se
1. Set goals of mean or diastolic blood pressures.
2. Individualize the arterial pressure targets goals.
3. Vasopressors induce an endogenous fluid recruitment and may limit positive fluid balance.
4. Reassess fluid status and cardiac output after initiation of vasopressors
2. Individualize the arterial pressure targets goals.
3. Vasopressors induce an endogenous fluid recruitment and may limit positive fluid balance.
4. Reassess fluid status and cardiac output after initiation of vasopressors
5. Consider agents with a different mechanism of action as a second line agent.
6. Consider adding hydrocortisone in patients on high doses of vasopressors.
7. Vasopressin is an option in patients with right ventricular failure.
8. There is no maximal dose of vasopressors.
6. Consider adding hydrocortisone in patients on high doses of vasopressors.
7. Vasopressin is an option in patients with right ventricular failure.
8. There is no maximal dose of vasopressors.
A thread on mechanics, logistics and reasons behind positive end expiratory pressure (PEEP) significance while handling patients on mechanical or non-invasive ventilation 🧵
#MedTwitter #EDTweeter #PulmTwitter @PulmPEEPs
#MedTwitter #EDTweeter #PulmTwitter @PulmPEEPs
PEEP is the air pressure that stays “WITHIN” the lungs after a person finishes exhaling. Now, this PEEP pressure is always greater than atmospheric pressure. It essentially prevents the alveoli’s to collapse and maintains the airways open.
CPAP is a non-invasive mode of ventilation which works by the same principal of PEEP, I.e. to provide end expiratory positive pressure
EPAP means expiratory positive airway pressure which works with the same logic & dynamics of PEEP, but is used for patients receiving BPAP
EPAP means expiratory positive airway pressure which works with the same logic & dynamics of PEEP, but is used for patients receiving BPAP
Is direct discharge to home (DDH) from ICUs safe?
1. Patients are usually transferred to hospital wards from the ICUs and discharged to home after another few days. However, there could be delay in getting a ward bed or patient might have significantly recovered while in ICU.
1. Patients are usually transferred to hospital wards from the ICUs and discharged to home after another few days. However, there could be delay in getting a ward bed or patient might have significantly recovered while in ICU.
2. Moreover, some families find it difficult to afford longer duration ICU (& hospital stay) costs. This necessitates direct discharge to home (DDH) in some patients. In a recent study, the safety of DDH was evaluated and compared to those who were transferred to wards from ICUs.
3. For DDH from ICU, compared with ward transfers, there was no difference in the risk of-
*Emergency department visits at 30-days (22.4% vs 22.7%);
*Hospital readmissions at 30-days (9.8% vs 9.6%); or
*90-day mortality (2.8% vs 2.6%).
#MedTwitter #CriticalCare #ICU
*Emergency department visits at 30-days (22.4% vs 22.7%);
*Hospital readmissions at 30-days (9.8% vs 9.6%); or
*90-day mortality (2.8% vs 2.6%).
#MedTwitter #CriticalCare #ICU
An INCREDIBLY intimidating part of the ICU can be the patient exam in the AM:
A 🧵on what to assess at bedside while taking care of an intubated/sedated patient.
(Because @tammamtu made an excellent point on another 🧵)
#MedTwitter #MedEd #Medicine #CritCare #ICU #CriticalCare
A 🧵on what to assess at bedside while taking care of an intubated/sedated patient.
(Because @tammamtu made an excellent point on another 🧵)
#MedTwitter #MedEd #Medicine #CritCare #ICU #CriticalCare
1. Talk to the patient, no matter their mental status. You should introduce yourself & announce what you’re doing during a physical exam. Sometimes we forget that there’s a loved one surrounded by all those machines & forget to act the same way we would if they were awake. Don’t.
2. Mental status: If they’re relatively responsive this one is much easier. If they’re not, this one is tough.
Assess sedation level. RASS is a commonly used descriptor. Most patients (not all) should be +1 to -1. If they’re -5 and on max sedation, you should explore that.
Assess sedation level. RASS is a commonly used descriptor. Most patients (not all) should be +1 to -1. If they’re -5 and on max sedation, you should explore that.
ICU pre-rounding tips:
I feel like early on, knowing what matters in the ICU is REALLY tough. So here’s what I typically do:
A 🧵 inspired by @akhadilkarMD’s pre-round thread (you should check that one out too!)
#MedTwitter #MedEd #CritCare #ICU #medicine #criticalcare
I feel like early on, knowing what matters in the ICU is REALLY tough. So here’s what I typically do:
A 🧵 inspired by @akhadilkarMD’s pre-round thread (you should check that one out too!)
#MedTwitter #MedEd #CritCare #ICU #medicine #criticalcare
1. If you can get at least some of this information automated for a printout, that can be invaluable. Whether that’s an updateable .dotphrase or a printable page from EPIC/Cerner etc. — save the carpal tunnel for later and just make notes on the data!
2. Start with a page that allows you to trend vitals. Particularly helpful is one with vitals and vasoactive gtts :
Is the MAP the same all night but the levo is down OR struggle to get a MAP >65 & escalate to a second pressor?
The #’s are important, but the TREND is essential.
Is the MAP the same all night but the levo is down OR struggle to get a MAP >65 & escalate to a second pressor?
The #’s are important, but the TREND is essential.
MAPSE in #IntensiveCare (with examples)🧵#FOAMcc #FOAMed #MedTwitter #Hemodynamic #POCUS #EchoFirst #CriticalCare
Take homes:
1⃣ Redefining "the hyperdynamic heart" with #MAPSE
2⃣ MAPSE is better than EF in the #ICU
3⃣ Linking MAPSE with supply/demand-ischemia
1/n
Take homes:
1⃣ Redefining "the hyperdynamic heart" with #MAPSE
2⃣ MAPSE is better than EF in the #ICU
3⃣ Linking MAPSE with supply/demand-ischemia
1/n
1⃣ Can MAPSE redefine "the hyperdynamic heart?
The term "hyperdynamic LV" - EF > 55% - is misleading. It has no relation to a hyperdyanmic circulation; SV/CO. Someone bleeding to death has a hyperdynamic heart, but the circulation is life-threatening hypodynamic.
2/n
The term "hyperdynamic LV" - EF > 55% - is misleading. It has no relation to a hyperdyanmic circulation; SV/CO. Someone bleeding to death has a hyperdynamic heart, but the circulation is life-threatening hypodynamic.
2/n
MAPSE is cardiac motion, and defining the hyperDYNAMIC heart as good cardiac motion makes perfect sense. Recent geometrical analysis of cardiac pumping shows that MAPSE is the main determinant of SV. Fig from @mugander: tinyurl.com/mxbfmcyk
Why?
3/n
Why?
3/n
A case of low ScvO2 (60%), high PvaCO2 (8.2 mmHg), fluid intolerance (CVP 11) and fluid responsiveness (PPV 17). What's the physiology and what to do?
#FOAMcc #Hemodynamics #ThePeoplesVentricle #FOAMed #Fluidtolerance #Cardiotwitter #CriticalCare
#FOAMcc #Hemodynamics #ThePeoplesVentricle #FOAMed #Fluidtolerance #Cardiotwitter #CriticalCare
Post-cardiac surgery. MAP 70, HR 95, low dose pressor. High CVP (11 mmHg) with pathologic waveform of x < y-descent. PPV > 17 despite low Vt (< 6 mL/kg). Normal blood gasses, normal lactate.
Reasons I love #neurology
1. 2022 is my 25th year in Neurology. I enjoy this subject many times more than 1998, when I entered this branch as a #resident at @OffCMCVellore I was dissuaded by many of my teachers to take up DM in another specialty but I stuck to Neurology
THREAD
1. 2022 is my 25th year in Neurology. I enjoy this subject many times more than 1998, when I entered this branch as a #resident at @OffCMCVellore I was dissuaded by many of my teachers to take up DM in another specialty but I stuck to Neurology
THREAD
2. Neurology is vast: If you love reading, there are several topics you can read. There are about 600 common #diseases in Neurology to read about. Newer diseases are being discovered, so there is no dearth of new topics to learn about.
3. History & physical examination are still the most important to arrive at a diagnosis. Whether it is epilepsy, migraine, stroke, Parkinson's disease or Alzheimer's disease, history & physical are more valuable than any investigations. MRI, EEG & EMG contribute but are not final
NEXT:Interfacing ICU data Nicolas Bennet
- Nicolas was very pleased to hear Chris Sauer(earlier speaker) advocating use of 2 -data set at least
@ESICM #criticalcare #ai #ml #icudatasets
- Nicolas was very pleased to hear Chris Sauer(earlier speaker) advocating use of 2 -data set at least
@ESICM #criticalcare #ai #ml #icudatasets
@ESICM eth-mds.github.io/ricu/
showcasing this R dataset
starting with
'r'
> library(ricu)
> lact (loaded all lactate data)
'r'
showcasing this R dataset
starting with
'r'
> library(ricu)
> lact (loaded all lactate data)
'r'
@ESICM NEVER THOUGHT THAT I would be tweeting code in an ICU conference :)) @ESICM #datascience :P #datascience #LIVES2022
NEXT Inventory and Comparison of ICU datasets by Christopher SAUER
"Why talk on differences in ICU databases?"
Ans: becuase data is "CORE"
@ESICM #ml #ai #databases #datascience #LIVES2022
"Why talk on differences in ICU databases?"
Ans: becuase data is "CORE"
@ESICM #ml #ai #databases #datascience #LIVES2022
@ESICM Merit of publicly available ICU databases
- no randomzined evidence exists for most clinical situations
-data and pt level insights incredibly useful.
-local epidemiology and treatment difers
-real world data sets help deliver optimal treatment policies.
#DataScience #LIVES2022
- no randomzined evidence exists for most clinical situations
-data and pt level insights incredibly useful.
-local epidemiology and treatment difers
-real world data sets help deliver optimal treatment policies.
#DataScience #LIVES2022
@ESICM 1st publicly available dataset MIMIC-3 in 2016,
Beth Israel Deaconess Medical Centre, Boston,MA
>70,000 icu stays, 2008 to 2019
now also includes chest x-rays, emergency room data
- large, community developed Github repo.
#DataScience
Beth Israel Deaconess Medical Centre, Boston,MA
>70,000 icu stays, 2008 to 2019
now also includes chest x-rays, emergency room data
- large, community developed Github repo.
#DataScience
Day 2. Starting on pitfalls in leveraging EHR by Stephanie HYLAND @ESICM #criticalcare #ehr #datascience #ai #LIVES2022
This problem is mainly for ML engineers who may not have talked to domain expert or clinicians / end users.
Pitfall 1 : sampling bias
"whos included in the analysis"
"who in your EHR"?
- e.g., - COVID prediction dataset where missing all blood tests were removed, but this missingess has a meaning. Thus not generalisable.
e.g., yesterday I mentioned about females < 6% of sample popn
"whos included in the analysis"
"who in your EHR"?
- e.g., - COVID prediction dataset where missing all blood tests were removed, but this missingess has a meaning. Thus not generalisable.
e.g., yesterday I mentioned about females < 6% of sample popn
Amsterdam UMC on Implementation: @drPaulElbers Conference conflicts of interest : chair of data science edition.
"Working AI to Implementation"
#criticalcare #DataScience #ai #aitobedside #LIVES2022
@ESICM
"Working AI to Implementation"
#criticalcare #DataScience #ai #aitobedside #LIVES2022
@ESICM
@drPaulElbers @ESICM PacMed Model to help discharge patients from ICU. Autokinetics for antibiotic dosing.
These 2 are currently implemented. @patrickthoral also involved in discharge models.
These 2 are currently implemented. @patrickthoral also involved in discharge models.
@drPaulElbers @ESICM @patrickthoral - ICU natural habitat
- large vol of data
- frequent decision making
BUT there is a problem in ICU and data.
- high variability
pubmed.ncbi.nlm.nih.gov/36173632/
- large vol of data
- frequent decision making
BUT there is a problem in ICU and data.
- high variability
pubmed.ncbi.nlm.nih.gov/36173632/
NEXT: Who's "high risk" in ICU? Nicolas Bennett - Zurich, Switzerland.
reminds me of NELA score development in UK.
Declaration : he now works for industry (known side effect for medics doing data science )
@ESICM #criticalcare #ai #datascience #LIVES2022
reminds me of NELA score development in UK.
Declaration : he now works for industry (known side effect for medics doing data science )
@ESICM #criticalcare #ai #datascience #LIVES2022
@ESICM Interesting : eventually end up writing R package. cran.r-project.org/web/packages/r…
#sepsis classification using MIMIC-3 - time series data. Time-series classficiation.
#sepsis classification using MIMIC-3 - time series data. Time-series classficiation.
Starting with "Whats *HOT* in data science?" Kirsten COLPAERT
- hype cycle for data science & ML in 2022.
- innovation trigger -> peak of inflated expectations -> trough of disillusionment
#LIVES2022
#datascience #WeAreICU #TogetherICU #IntensiveCare #CriticalCare @ESICM
- hype cycle for data science & ML in 2022.
- innovation trigger -> peak of inflated expectations -> trough of disillusionment
#LIVES2022
#datascience #WeAreICU #TogetherICU #IntensiveCare #CriticalCare @ESICM
Still some time for newer tools. Aiming for path towards productivity.
Potential usage of "Synthetic data" to "preserve privacy" and "augment unbalance/or biased data". This is potentially interesting as it allows more transportability of models from one health care system to others.
FINAL day 2 of 2 : WEANING . Lisanne Roesthuis. Weaning definitions starting with WIND study. #LIVES2022
#ventilation
#weaning #WeAreICU #TogetherICU #IntensiveCare #CriticalCare
@ESICM
#ventilation
#weaning #WeAreICU #TogetherICU #IntensiveCare #CriticalCare
@ESICM
@ESICM pubmed.ncbi.nlm.nih.gov/27626706/ Successful weaning (or successful separation) - extubation without death or reintubation within next 7 days. same for tracheostomy.
Different groups and trajectories
NEXT :: COPD - Oriole Roca.
Evidence : NIV is great for acute COPD. The classic from Laurent Brochard pubmed.ncbi.nlm.nih.gov/7651472/
Evidence : NIV is great for acute COPD. The classic from Laurent Brochard pubmed.ncbi.nlm.nih.gov/7651472/
but if beyond 24 hours. alternative is High flow nasal cannulae.
#LIVES2022
#ventilation
#NIV #COPD @ESICM
#LIVES2022
#ventilation
#NIV #COPD @ESICM
@ESICM NIV failure - intubat the patient, COPD patient intubated, Vol Control, 7ml/kg PBW, I:E = 1:4 , RR 20. Then patient is "hypotensive". why?
