Discover and read the best of Twitter Threads about #FOAMcc

Most recents (24)

ICU stories (a common one): It's Saturday, Jan 28, 2023. You just came on service at 7:00 am & at the same time, they were rolling in a case from the OR (Friday night case = never good...). 65 yo pt w DM2/diastolic HF/CAD/A fib/HTN/PVD. Had 10 ds' hx of abd pain; CT A/P showed
evidence of ischemic bowel. Pt came to the ICU after an exp-laparotomy w partial small bowel resection. The gut was left in discontinuity & the abdomen was left open. Pt still sedated & paralyzed, on norepi 0.18. A sleep-deprived anesth CRNA is telling you that the surgeon plans
to bring the pt back to OR for 2nd look on Monday. You feel so lucky; pt already has lines from the OR, you just have to keep him sedated for 2 days. Piece of cake! You move on to the other pts but the RN interrupts your dream rounds in 5 min. What about maintenance fluids, doc?
Read 19 tweets
After yesterday's #POCUS quiz, it's time to reshare these cardiac tamponade infographics.
Courtesy of @ACEP_EUS
Set of 3
See 🧵for the rest
#Nephpearls #MedEd #FOAMcc
Pulsus paradoxus #echofirst
Hepatic vein waveform changes
Read 5 tweets
A 58-year-old woman with no known comorbidities presents with progressive fatigue and shortness of breath x several months. Noted to have bilateral pedal edema; BNP 2,473 pg/mL.
#echofirst 👇❓
Answer and 🔗 to source in thread.
Left atrial myxoma -> pulmonary hypertension (RVSP 93 mmHg) -> RV dysfunction (Note obvious RV enlargement ☝️…
PLAX (same case)
Read 4 tweets
1/3-💥 12 KEY TRIALS I teach on #ICU Rounds each week trainees must know!

BACK by request!

Do you agree?
Any you would add?

1. ARDSNET @NEJM -PMID 10793162

2. LEUVEN Glucose 1 @NEJM-PMID 11794168

3. SAFE Trial @NEJM PMID: 15163774
#FOAMcc #MedTwitter #MedEd
2/3 12 Key ICU TRIALS I teach each week

4. TRICC Trial @NEJM PMID: 9971864

5. SOAP Vasopressor trial @NEJM PMID: 20200382


7. Rivers EGDT @NEJM PMID 11794169

8. VAAST Trial @NEJM PMID 18305265

9. SMART Fluids @NEJM PMID 29485925
💥 3/3 12 KEY ICU TRIALS I teach each week continued…


11. Schweickert Early Mobility @Lancet PMID19446324

12. ABC Trial @TheLancet PMID 18191684

What others would you add?

#FOAMcc #FOAMed #SCCMSoMe #MedTwitter #MedEd #MedStudentTwitter
Read 3 tweets
ICU stories (a brief one): One hour before the end of the am shift, u walk around in the ICU to make sure thinks look OK before u type your sign-out note. You spot the resp therapist & the nurse bagging the pt in Rm 306. From the hallway, u see the monitor: HR 160, RR/45, Sat 70%
This is a 30 yo pt w hx of a catastrophic brain bleed, s/p trach & PEG, admitted 2 wks ago w MDR Klebsiella UTI. Doing well, on trach mask 28%, until the episode of acute/unexpected desaturation
When u examine the pt, s/he is in extremis (accessory muscle use-tachycardic-tachypneic-diaphoretic). BP: 105/55. You grab the stethoscope that the resp therapist wears around his neck & you hear breath sounds in both sides (pt is skinny...)
Read 24 tweets
#POCUS image of the day:
Fox tail sign - left pleural effusion visualized from the apical cardiac window.
#MedEd #FOAMcc #FOAMed
#anatomy correlation
Read 3 tweets
4 RCTs published in the last few hours you can’t miss if you work with critically ill patients:

#1 Fluids in septic shock
#2 Mobilisation and long-term cognitive impairment
#3 NIV for extubation of obese patients
#4 Nutrition before extubation

A thread 🧵👇

#FOAMcc #SCCM2023

#CLOVERStrial compared a restrictive fluid strategy (with early vasopressors) to a liberal one in septic shock patients.

➡️ Restrictive fluid strategy (with early vasopressors) did not result in significantly lower (or higher) mortality



What’s the effect of early mobilisation on long-term cognitive impairment in ICU survivors after mechanical ventilation?

➡️ Early mobilisation improved long-term cognitive impairment at 1 y (24% vs 43%) but increased adverse events (6%)


Read 6 tweets
✅Updated norepinephrine equivalent score

How can you compare the potency of the following vasopressors?

1️⃣Norepinephrine: 0.2 μg/kg/min
2️⃣Vasopressin: 0.04 U/min
3️⃣Angiotensin II: 20 ng/kg/min

Our new publication gives you the answer👇

The norepinephrine equivalent (NEE) score tells you the dose of each vasopressor necessary to reach the target MAP with reference to norepinephrine.

You can find one example of NEE in the table below.
You may notice that some vasopressors are missing in the table above.

Therefore, we have included new vasopressors (e.g., angiotensin II, methylene blue) and updated the NEE score.

We also described the history, utility, and pitfall of NEE score.
Read 4 tweets
These books from @accpchest & @SCCM represent my study goal for this month. Before starting any (re-)certification exam & especially f you want to ace the tests, there are a few recent trends (& old habits/tricks) that you need to be aware of:
1. If there is an option of "doing nothing", this is most likely the correct answer.
2. There is always a mixed metabolic disorder. Memorize Winter's formula.
3. Prepare for several COVID-19-related questions. No surprise here...
4. TEG is very popular. Even of you are a dinosaur, you have to learn the basics about visco-elastic tests.
5. I know you have no CAR T-cell therapies in your hospital (& no one can really spell them correctly), but be prepared for managing cytokine release syndrome.
Read 9 tweets
ICU stories: 65 yo pt, fairly healthy besides HTN & an episode of diverticulitis 3 y ago, is brought to the ED due to 2 wks' hx of abd pain & 1 d hx of N/V ("coffee-ground"). Looked "bad". SBP in 60s - improved to 80s w ivf. Intubated. Had CT A/P 👇:
While you review the CT images, you get the lab results: Lactate 10, WBC 3K, INR 2.0, BUN/Creat 100/3.0, CRP 500 mg/l, Procalcitonin 300. The ED is calling you for the admission. What consult(s) do you ask?
The CT A/P showed a large amount of free intra-peritoneal air; stomach & SB were mildly distended & partially fluid-filled. There was colonic diverticulosis without diverticulitis & mild wall thickening involving the descending colon & the sigmoid colon
Read 13 tweets
ICU stories: 70 yo pt without medical hx but tobacco use (2 ppd x 40 y) was admitted w shortness of breath a wk ago. CXR/chest CT without PE/infiltrate. Was in afib/RVR on admission; placed on heparin & dilt/b-blocker (w some hypotension). Remained dyspneic, at times restless,
“requiring” multiple sedatives, & eventually was brought to the ICU. Intubated for "resp distress" & mental status changes. "Formal" echo, the day of ICU transfer, showed “LVEF 20% w global LV dysfunction”. On the vent 50% - peep 10. BP 110-130/60-70. Lactate < 2.0
Cards follow for "well compensated heart failure". A look w POCUS upon ICU admission:
Read 20 tweets
How do you examine the lower extremity venous system when you look for deep vein thrombosis? What points do you check with the probe? Do you use Doppler? What are the recommended protocols? The Society of Radiologists in Ultrasound recommends a complete duplex ultrasound:
👆 The black rectangles represent the extent of the compression US. The gray rectangles are the sites of Doppler.
2-CUS (2-points compression US) includes compression of the femoral veins 1-2 cm above & below the saphenofemoral junction & the popliteal veins
up to the calf veins
ECUS (extended compression US), includes compression US from the common femoral vein through the popliteal vein up to the calf veins confluence

CCUS (complete compression US), includes compression US from the common femoral vein to the ankle
Read 9 tweets
Following up on a discussion during ICU rounds this am: Like most laboratory values in medicine, pH and lactate levels should be evaluated in their context. In this 👇 old study of 6 male oarsmen who participated in a maximal effort on a rowing ergometer, Image
the two lowest pH values were 6.74 and 6.76 (corresponding to [H+] of > 180 nmol/L); the HCO3 levels were undetectable. The lowest lactate level was 32 mmol/l. The oarsmen remained conscious and did not require medical help Image
The conclusion of the study was that "in healthy humans, pronounced, but transient,acidosis is well-tolerated". Finding a pH of 7.05 or a lactate of 10 is usually not a big deal in a patient with DKA or (post-)seizures
Read 4 tweets
#POCUS quiz
You are performing physical examination in a patient with suspected fluid overload (plethoric IVC).
Parasternal short axis view demonstrates D-sign. But what's in the RV?
Apical view in thread.
#Nephrology #MedEd #FOAMcc
🔗 to source will be posted in a few hours.
Apical #POCUS
As our friends said, it's prominent moderator band in a patient with RV hypertrophy + prominent trabeculae.
Source article 🔗…
Read 4 tweets
ICU stories (a boring one…): If you work in a general ICU of a community hospital in United States, one of the common admissions you will get is the unfortunate resident of a nursing home or rehabilitation center that lives there for several decades & at some point becomes
febrile/“altered” & is sent to the ED for “evaluation”. The course is so predictable that we usually consider these admissions “boring”. This is the case of a middle-aged pt w cerebral palsy/mental retardation/seizures (on valproic)/PEG-chronic Foley in place who was sent to
the ED for fever+hypotension+tachycadia. Labs: WBC 15k, lactate 4.0. UA -as usually- suggestive of UTI (WBC>50, +bacteria, +nitrite, +esterase). CXR “clear” & pt w sat 99% on room air. Received ivf, Abx (pip/tazo + vanco) but due to persistent ⬇️BP, norepinephrine gtt was ordered
Read 25 tweets
New to the ICU?

Osler's catalogue of modules is completely free, and you can even print off a certificate of completion for your records!

Here's 10 great modules to get you started

#intensivecare #intensivist #ICU #FOAMed #FOAMcc #medtwitter @CICMANZ @anzics @ANZCA @acemonline
If your're going to do invasive procedures, you need to get the basics right
If you're new to mechanical ventilation, this will give you the basics

Read 12 tweets
It's December, already. The time of the year when I am trying to spend every last cent of the annual allowance given to us for continuing medical education (CME) by our employer. In essence, this is money that we have worked for and, since it won't carry over to next year, I hate
leaving it on the table. The problem is that if you buy a conference or a study course now, you have to watch everything - and submit proof of attendance/completion - before the end of the year. So, it's a very busy month dedicated to studying/reviewing educational material!
For example, I just finished watching the last one of the 93 lectures from The Hospitalist & Resuscitationist 2022 conference #HR2022. If you are an intensivist/internist/family medicine/EM physician, I have no doubt that u will find several pearls to bring back to your practice
Read 5 tweets
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
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.
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:
Read 17 tweets
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
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.
#EchoFirst #POCUS #TEE: Mildly reduced LV function; #MAPSE 5.75 mm. EF visually 45-50%. Small EDV.
Read 11 tweets
Alcohol withdrawal syndrome: I don’t know if u have a similar experience in other countries (or other places in the States) but I've recently seen a big spike in alcohol abuse-related disorders, especially alcohol withdrawal syndrome (AWS). I'm obviously referring to severe AWS
that eventually will need to come to the ICU (if we have a bed available!). There are many fantastic, well-searched reviews on this topic but it may be hopefully interesting for some if I put “my way” out there & also for me to learn from your experience. Even though the focus
will be on the neuropsychiatric component, I believe it is quite important to highlight other parts of AWS management. To this end, I will use the assessment/plan “per organ” approach which is commonly used when we write progress notes here in US. Here it goes:
Read 26 tweets
☑️HALLOWEEN 2022 @AirwayMxAcademy and @dasairway airway nightmare case🎃You are a critical care doc and decorating your ultimate Halloween party👻underwater cave with a healthy friend. The room is now flooding with water and your friend falls down on the rocks…oops😳1/13 #meded Image
2/13 “Are you okay?”Yes but I have difficulty breathing and it hurts. There is 1 scuba🤿unit, and you see a HFNO device & oxygen cylinder. You know that underwater breathing is possible with HFNO. How much flow is needed to swim 0,5 m below surface & b able 2breath underwater?
3/13 First you check the oxygen tubing which is long enough, than you check the class E oxygen cylinder: 1000 PSI. Save PSI 200. How much time/oxygen do you have at 40 l/min to swim underwater? #halloweenairway #foamed #foamcc #airway
Read 13 tweets
ICU stories: You get a call from outside 🏥 to accept a middle-aged pt w DM2/HTN/HLD/some type of solid Ca on chemo/obesity who presented to their ED w weakness/anxiety/"feeling cold". Vitals: BP 80-100, HR 130s (sinus tach), afebrile, Sat 100% on room air. Labs: WBC 13K, ...
... Lactate 5.2, creat 1.3. UA w some WBCs/bacteria. CXR clear. Norepi drip ordered but cancelled after BP improved to mid-90s, HR fell to 120s, & lactate ⬇️ to 2.5. What's your next step?
The discussion went like this:
Me: I will be happy to accept but I have no idea what we are treating. If it is sepsis, the source is unclear. And what about PE? Can you pls get a CT before sending?
ED: Sure, will do it. Thanks.
You go home & next am you learn that the CT showed:
Read 21 tweets

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