Discover and read the best of Twitter Threads about #FOAMEd

Most recents (24)

Does Vitamin C, Thiamine, and Hydrocortisone cure sepsis?

Is this "cocktail" the wonder drug that the media hype implied in 2017 based on ONE before-after retrospective study?

Answers from the 1st major international randomized control trial ARE HERE! @JAMA_current.

Let’s not bury the lede here.

*This trial is PROFOUNDLY negative*

The authors (Fujii et al) found the vitamin C cocktail to have NO effect on the primary outcome: time alive and vasopressor free days.
The authors also found no effect in 9 of 10 secondary outcomes including 28 day mortality, 90 day mortality, need for mechanical ventilation, renal replacement therapy (dialysis) and others (see below).
Read 25 tweets
Here’s a great #ECG of a man who presented to the ER with crushing chest pain.

Here’s the ECG Computer Read:

"Non-specific ST abnormality, consider anterior subendocardial ischemia."

Take a good look at Leads V1-V3 and burn this morphology and pattern into your mind.

THIS is what Posterior #STEMI looks like on a Standard 12-Lead ECG!

Read 12 tweets
Reading more about venous air embolism after putting in/removing ~10 CVCs in last 2 weeks is kind of freaking me out so I decided to do a deeper dive

#FOAMed #FOAMcc #EmergencyMedicine
🔺Symptoms: acute onset dyspnea, cough, syncope, AMS, “mill wheel murmur" (specific but not sensitive)

🔺Clinical manifestation: acute R-heart failure, cardiogenic shock (hypotension, oliguria, JVD), acute embolic stroke (air bubbles pass thru patent foramen ovale)
🔺Clinical Dx but can use:
🔹EtCO2: decreased due to increase physio dead space & worsening V/Q mismatch
🔹EKG: signs of R-heart strain (R axis deviation, RBBB, peaked P waves), non-specific ST changes
🔹TTE/TEE: Air in cardiac chambers, RV dilation
🔹CXR: pulmonary edema
Read 7 tweets
Recently our team had to manage a patient who presented critically unwell from post-tonsillectomy hemorrhage - something you may not see that often but can be a true life-threat!

(pictured is only one of several buckets)

My tips here:


Tip 1: Call for help early!

This patient did well because of excellent #teamwork from scene to OR. We received an alert from the EMS team, and informed ENT early (not in house) to the situation and need for OR. Anesthesia and OR team were also informed to prepare for this

Tip 2: Keep the patient sitting upright

Position is key. This patient was awake & alert, and keeping them upright allowed them to spit out the blood. Give them the suction to use also.

Read 9 tweets
1/15 #Fever #tweetorial

Parents and paediatricians alike are obsessed with fever

We've all got fever fever 🔥 But it is SO misunderstood

Let's take a look at what fever actually is, and finish off with some myth busting!

#FOAMPed #FOAMed #IDTwitter #PedsICU #PedsID
Fever (pyrexia) is an elevated core body temperature as part of a physiological response to infection controlled by the hypothalamus

This is opposed to hyperthermia, a pathological elevated temperature

This is important, as your body is IN CONTROL. Fever happens on purpose
What temperature counts as a fever?

There's no strict definition (there's no really good data on what a "normal" temperature is...), but an arbitrary cut of off 38C is often used.

Its better taken in context; 37.8C following temps >38.5C is probably still a fever.
Read 15 tweets
#tweetorial time for SUPER FAST, no WINTER or (difficult) MATH evaluation of Anion-Gap Metabolic Acidosis:


The metabolic seesaw:

(more BC)

dAG = delta Anion Gap
dBC = delta Bicarbonate.
Toward the Center = more bicarbonate

This will all make sense in a moment.

Scene: patient w/ anion-gap metabolic acidosis

Your ?: is their compensation appropriate? Do I need more labs? Who and what is a winter and why do they have a formula?!?!

Answers: seesaw only, a chemistry is all you need!

Read 12 tweets

AKA "jams" (XR neg)

Often worse than they seem

EXAMINE the patient
Check FDP & FDS, EDC, and CENTRAL SLIP (Elson test) as well as jt stability

"XR neg, go home" = WRONG ANSWER

Acute tx much easier & more reliable than chronic
#medtwitter #foamed
If missed, central slip tears progress to BOUTONNIERE deformity

Perform Elson test to check CS integrity for all "jammed fingers"

Flex PIP over a table edge and hold down P2. Ask them to extend DIP. If they CAN, it's ABNORMAL & sign of tear (2/3) #medtwitter #foamed
Or, "Modified Elson test"

Align P2s back to back

Ask pt to extend DIP

Normally unable to, but if central slip torn, they can extend the DIP through the lateral bands

Either learn this or send all to hand for eval

Acute treatment = easy
Chronic = not (3/3)
#medtwitter #foamed
Read 4 tweets
“The Erythemas” – A #dermatology #meded #FOAMEd #tweetorial. pc:@dermnetnz

Ever get all the different #dermatologic terms jumbled up? Was it erythema nodosum, erythema migrans, or erythema multiforme?

Honest poll – Ever write “rash” b/c you couldn’t remember the diagnosis?
All kidding aside, these terms can get confusing. Remember though, derm terms are usually just descriptors of what you see. The name tells you all you need to know.

For example: Acute Generalized Exanthematous Pustulosis (AGEP) = pustules suddenly appeared everywhere!
So, the “erythemas.” First off, what does “erythema” actually mean? Well, according to my Google machine, it's from the Greek root “eruthros” meaning “red.” So "erythema" doesn’t add much to our knowledge of what the rash looks like other than it’s red, and so, likely inflamed
Read 15 tweets
@BenTritle presenting an Update on IR-guided central line access! #meded #foamed @CleClinicMD
Different central line access:
Dialysis catheters and Port catheters:
Read 10 tweets
"What is the best Venous Access Device for my patient?"

An #InterventionalRadiology (#Irad) #Tweetorial to address a frequent clinical dilemmas for #Medtwitter and #NurseTwitter


Type of VAD:

PIV: 3-6 cm, enter and terminate in peripheral veins.

US-PIV: US to reach deep veins when superficial veins difficult to palpate, ≥8 cm

Midline catheter: 7.5-25 cm, inserted basilic/cephalic vein), terminating short of subclavian. 🚫 vesicant infusions

CVC: duration 7-14 d, direct puncture of internal jugular, subclavian, or femoral veins.

TC : diff from CVC, seperate insertion site in upper chest and venipunture in neck
⬇️ risk of infection due to cuff
👍 location for catheter care
Read 15 tweets
Another day on service and you are starting with answering a page from PACU. "Hi this is nephrology fellow returning your page". "Great! This is Ortho, and our patient post op has low potassium here; I believe you call it HYPOkalemia" #Loveourorthopods #Tweetorial #medthread
Join us for our electrolyte abnormality du jour and learn how to break it down! #nephtwitter #medtwitter #FOAMED See our full post @RenalFellowNtwk >…
59 yo F with a hx of HTN, and HLP admitted for a left femur fracture; she was found down by her neighbor 3 days after her fall; awake and in pain. Now, patient is post op; and on labs: (baseline cr: 0.51). UA unremarkable.
Read 19 tweets
@tavrkapadia delivering @CleClinicMD Grand Rounds. On #TAVR. Starts by showing how morbid and complex the open surgery is. Many elderly patients are not candidate. Hence #TAVR was developed. #meded
The team that ensures ZERO percent mortality in #TAVR for any patient coming to @ClevelandClinic with Aortic stenosis. #meded
Heart is NOT stopped! After #tavr can see immediate hemodynamics improvement!
Read 10 tweets
ERYTHEMA MULTIFORME – a #dermatology #tweetorial/#medthread!

#MedEd #FOAMEd #dermatologia #dermtwitter #medtwitter #derm pc: @dermnetnz

Let's warm up with a question for all y'all tweeps out there!

What is the most common trigger for erythema multiforme (EM) in adults?
EM is an immunologic syndrome usually triggered by infection in adults. We usually consider HSV and mycoplasma. A simple history for cold sores or genital ulcers can be telling, but mycoplasma can go undetected symptomatically.

What primary lesions do you expect in EM?
EM is usually made up of papular (raised) targets. Pic1 is of EM; you can see the 3 zones in a typical target (red rim, then white, then red center). Versus SJS/TEN (pic2), where macular targetoid (2 zones of red rim, dusky center & flat).

2nd photo:…
Read 10 tweets
Herniación Cerebral en Traumatismo Craneoencefálico
#PedsICU #FOAMed #MedEd

Abro hilo, iniciamos y abiertos los comentarios👩‍⚕️👨‍⚕️
Último hilo del año sobre la serie de #TCE.
Antes de iniciar, te dejamos los 4 enlaces de la serie completa (#tweetorial):

1. Abordaje Prehospitalario e Inicial en el TCE
Todo empieza antes de llegar al Hospital, así se logra el mejor desenlace.

2. Cuidados basales en el #TCE Severo
Lo que todo paciente con Escala de Coma de Glasgow igual o menor de 8 debe recibir.

Read 31 tweets

attention every1 in #primarycare #urgentcare #emergency care #EM or #ortho #radiology

Here's an injury that gets missed SO FREQUENTLY

but not by you anymore, bc now YOU'RE GONNA CATCH IT!

Hx: punched a wall, pain
#medtwitter #foamed
What's that? You want another view?

Think you spot the problem?

Keep scrolling!
#medtwitter #foamed

The MC5-hamate articulation is outlined in orange dots

Best appreciated on a 30 deg pronated oblique

Sometimes these are subtle on AP and LAT but always a dead giveaway on the oblique

#medtwitter #foamed
Read 5 tweets
1/8 #FOAMPed #PEM #FOAMed

Another chat in CED last night about using Ibuprofen in chickenpox, and thought it would make a nice tweetorial! (for more detail check out end of thread for link to blog and podcast!)

Ever heard you shouldn't given ibuprofen to kids with chickenpox?
The concern is about increased risk of severe skin infections, in particular the dreaded necrotising fasciitis (nec fasc) with group A Strep (GAS).

This first popped up in the 60's with case reports of a GAS outbreak associated with ibuprofen.…
A few case control studies have been done since, with small sample sizes (Nec fasc is rare!) which seemed to confirm an association.

But, as you all know, correlation does not equal causation!…
Read 8 tweets
Here is a gorgeous case of CTD-ILD. I found this whole entity very confusing at first. I’ll show images at presentation, 7 days, 2 months, and 6 months. I’ll also share PFTs, BAL, serology, and path report. Please comment on these if you like. #FOAMed #FOAMrad #radres 1/
The patient is a 45 yo male. Acute kidney injury and ? Pneumonia. The first image was at presentation. There is peribronchial consolidation with a nice perilobular appearance peripherally. Looks like organising pna. Cause could be infection, vaping, drug reaction, CTD...
Here is a similar level, 7 days later. Consolidation has progressed. OP is really just a type of lung injury. If the lung injury gets worse, we could get into ARDS/AIP territory. But, no septal lines and no effusion. So just bad OP. ANA is elevated.
Read 15 tweets
1/ A short #tweetorial introducing human leukocyte antigen (HLA) and important and often confusing topic in #transplantation #kidneytransplant

#FOAMed @MedTweetorials

What is an "HLA"?

HLAs = cell surface proteins encoded by highly polymorphic major histocompatibility complex (MHC) genes on Ch 6 🧬

In #transplantation, HLA proteins are #polymorphic antigens ➡️ alloreactive trigger for the immune response ➡️ can ultimately lead to organ #rejection ☠️
3/ The 2 primary classes of MHC molecules are 1⃣ and 2⃣.

Class 1⃣ MHC are found on the cell surface of ALL nucleated cells + platelets. Their role is to present intracelleular peptide fragments to CD8 #Tcells
Read 8 tweets
(Thread) Another week and another @MedTwitThisWeek #medthread. As a reminder, this is not all inclusive. It's a jumping off point. A continuation of the discussions from the week that I found interesting including conferences, #Tweetiorials and tributes. #medttw #FOAMed
2/ Conference Bonanza! Since last week, several amazing conferences took place (or just started). Each conference has their own hashtags and flavors of #SoMe. Here are some highlights...
3/ @jenreadlynn was at #midwesthospmed and did a great job of distilling @MelBreggs' talk on inpatient management of alcohol withdrawal.
Read 31 tweets
Watch this great video showing the Modified Valsalva Maneuver converting a patient in SVT to Normal Sinus Rhythm

If you’re not doing this, you’re not doing SVT right!

Video courtesy: @julesantosER

In the REVERT Randomized Controlled Trial the success rate was 43% vs. 17% for the standard Valsalva Maneuver!

Read about it here:…
A lot people have asked about the physiologic explanation for why the Modified Valsalva Maneuver works. I’m gonna do my best to explain it as I understand it.

Let’s start by taking a look at the body’s physiologic response to valsalva...
Read 9 tweets
A little while ago I tweeted about drugs that scare me. As a tox fellow, I meant they scare me when I hear someone overdosed. I didn't write that specifically, and got questions and a request for a longer explanation (from @pgyfun) of why I'm concerned. So, tweet thread:
Propranolol: most beta blockers tend to do ok in overdose, likely due to compensatory increase in SVR that maintains BP. Propranolol is nasty though - it's lipophilic and a sodium channel blocker, so can cause seizures, coma, and QRS prolongation/dysrhythmias
Bupropion: wonderful medication for depression, but is actually a pharmaceutical bath salt (has the same cathinone backbone). High risk of seizures in overdose, and large overdoses causes cardiogenic shock that we can't fix due to myocyte gap junction blockade
Read 10 tweets
.@ammo_uw is kicking off the Educator’s Development PG course at #CHEST2019 with Mark Lavercombe (ML), @pkritek and @williamkellymd .. follow this thread for #CHESTMedEd updates from this day long session!
Also engaging us today will be Dr. Lisa Moore. Here are all the sessions for all you clinical educators at #CHEST2019 #CHESTMedEd
ML: is up next: Application of Adult Learning Principles

- Be aware of limitations of adult learners eg, limited time
- Be aware of limitations in environment: eg. Interruptions, clinical work, variety of learners

Read 41 tweets
“What does a surgeon look like?”

A story for all ages, written by @JJcolemanMD , illustrated by @gracie_leo

#ilooklikeasurgeon #womeninmedicine #medtwitter #meded #foamed #storytime
Story thread below...
She woke up one morning and asked the Mirror, “What does a surgeon look like?”

But the Mirror did not answer.

She asked the World and asked “What does a surgeon look like?”

And the World did answer.
The World said,

“He is TALL and NOT small.”
“He is not too young or too old.”
Read 10 tweets
A quick thread on why I make and use algorithms for the evaluation and management of patients in the ED:
#FOAMed #EmergencyMedicine #Metacognition
There are two systems for the processing of illness presentations:
1) Intuitive: rapid, high-capacity, low-effort
2) Analytical: slow, cognitively taxing
In the emergency department, system 1 and system 2 processes are often initiated in parallel and may recur during the ED course.
Read 8 tweets

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