Discover and read the best of Twitter Threads about #FOAMcc

Most recents (24)

Time for a #CriticalCare #Tweetorial!

‼️Basics of CRRT for the non-nephrologist‼️

Exiting my typical #Neurology wheelhouse as I tackle some #FOAMcc topics for my own learning. Please join in on teaching and address any mistakes!

#EmoryNCCTweetorials
@EmoryNephrology
1/🧵
CRRT- What does it stand for?!

Continuous- Runs around the clock (sort of)
Renal- The beans!
Replacement- More of a rinse than a true replacement
Therapy- It helps!

@criticalbeansmd @EmoryNeuroCrit @caseyalbin @KrafteKraft4 @mallyaa @VijayanMD
2/🧵
Why do we use CRRT instead of HD?

Patient’s with hemodynamic instability (ie blood pressure is so low they can’t tolerate HD)

Conditions where you need to avoid large fluid shifts (like cerebral edema)

3/🧵
Read 21 tweets
@HedayatiMD breaking down wide complex tachycardias at #ResusX21

❗️Know how to differentiate WCTs
‼️If unstable ➡️ treat as VT until proven otherwise

❓What is fascicular VT❓More below👇🏼

#FOAMed #FOAMcc #CardioTwitter
⚡️Ventricular Tachycardia⚡️

🔺Very wide & regular
🔺Lead I & avF: both downward ➡️ extreme axis
🔺V1-V6: look for polarity ➡️all QRS the same (upward or downward)
🔺Fusion beat: wide complex QRS followed by narrow QRS
🔺Capture beat: run VT w/ 1 random narrow QRS then back to VT
SVT w/ bundle branch block (BBB)
🔺Different polarity in V1-V6 as opposed to VT
🔺Look at previous EKG for known BBB

If too too fast ➡️ consider accessory pathway ➡️ SVT with WPW

#FOAMed #cardiotwitter
Read 4 tweets
Dr @sergio_zanotti on Antibiotic Rationale at #ResusX21

⏱When to start antibiotics

💊Optimizing antibiotics

❌When to stop antibiotics

#FOAMed #FOAMcc
⏱Timing of Abx Initiation⏱

✅In Septic Shock, goal is to administer Abx ASAP (within 1hr)

🔺For every hour of delay of antibiotics in septic shock ⬆️ 6.1% odds ratio of death

🔺Less severe infection/sepsis > you have more time to decide what/if patient needs antibiotics
💊Which Antibiotic To Start?🦠

❗️Adequate choice affects mortality

Three factors to consider when making choice:

1️⃣Anatomic source of infection
2️⃣Pt characteristics (i.e. indwelling line > need MRSA coverage)
3️⃣Local antibiogram!

❌No role for empiric double coverage

#FOAMcc
Read 5 tweets
So it’s our first HOT TOPIC

The convalescent plasma arm of @remap_cap

Currently on channel 1 at #lives2021
@remap_cap Inclusion criteria below

Intervention: 2u convalescent plasma vs standard care
Read 6 tweets
1/3-BACK by request for NEW ICU TRAINEES!

💥 12 KEY TRIALS I teach on #ICU Rounds each week they must know!

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 continued…

4. TRICC Trial @NEJM PMID: 9971864

5. SOAP Vasopressor trial @NEJM PMID: 20200382

6. NICE-SUGAR @NEJM PMID 19318384

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…

10. APROCCHSS @NEJM PMID 29490185

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
New heart failure presentation and a BP like this 114/33?

👇

😯🚨

#FOAMed #FOAMcc Image
We often see a large pulse pressure in distributive shock (sepsis) from a low SVR (vasodilation)

Not everything is sepsis, don't be fooled! 🧐

When seen with an acute heart failure presentation 🫀🫁 it may be acute aortic valve regurgitation

Endocarditis is a common cause
Diastolic back flow into the LV through an incompetent aortic valve = low diastolic BP & elevated pulse pressure

Regurgitation can lead to pulmonary edema (LVEDP ⬆️, Left atrial pressure ⬆️ = pulmonary edema)

And poor forward cardiac output may cause hypoperfusion (Shock)
Read 5 tweets
Inoperable patients can now be offered a potentially curative surgery.

🔗 Read @annalsthorsurg: pubmed.ncbi.nlm.nih.gov/34111383/ and the thread 👇 #FOAMcc #FOAMecmo
2/

Here we report the 1st case of intraoperative use of VA-#ECMO in a patient with resectable lung cancer and bivasal critical coronary artery disease with prohibitive low EF (23%), and describe the benefits of this new indication.

🔗 pubmed.ncbi.nlm.nih.gov/34111383/ #FOAMcc #FOAMecmo
3/

Cardiovascular comorbidities often prevent patients with otherwise resectable early-stage lung cancer from undergoing surgery due to prohibitive peri-operative risk.
Read 8 tweets
THREAD and my infographic of the #TTM2 trial

#OHCA patients were randomised to #TTM at 33°C or normothermia (<37.8°C) with early fever treatment.

➡️ Mortality and poor neuro outcome at 6 months were not lower in the hypothermia group.

🔗 nejm.org/doi/full/10.10… #FOAMcc Image
Guidelines recommend selecting and maintaining a constant target #TTM between 32 and 36 °C in comatose post-cardiac arrest patients to prevent hypoxic-ischemic brain damage.
(strong recommendation, moderate-quality evidence). #FOAMcc Image
Two RCTs published in 2002 showed an improved survival and neurologic outcome in patients resuscitated from OHCA of presumed cardiac cause and shockable rhythm who underwent hypothermia at 33°C. #FOAMcc Image
Read 6 tweets
Radiology in ICU - 1 - A Tweetorial of some interesting (and some very rare!) cases relevant to ICU on @Radiopaedia #FOAMed #FOAMcc #FOAMrad
Can we just take a minute to appreciate the tremendous resource of @Radiopaedia - the best radiological resource of our age - #FOAMed. Shared and open learning. #FOAMcc. Follow the links to see the cases in beautiful detail with Radiological commentary. radiopaedia.org
Empyema necessitans (EN)=rare complication of empyema with extension of the fluid collection and infection to the subcut soft tissue. Most common cause = Mycobacterial infx. Others = actinomyces, streptococcus, and staph infection. radiopaedia.org/play/35878/ent… (Dr J Yeung rID: 13415)
Read 22 tweets
Mucormycosis in ICU - A Tweetorial (Relevant due to #COVID19 in India) #FOAMed #FOAMcc
It's an invasive mould. Mucormycosis is a unifying term for infections belonging to 'Mucorales' - (so, Rhizopus, Mucor, Absidia etc). The fungi are filamentous. It's also all around us. pubs.rsna.org/doi/full/10.11…
Pulmonary infection is clinically indistinguishable from more common moulds such as invasive pulmonary aspergillosis (IPA) - PLUS, it's not a reportable disease, which makes it (obviously) underreported.
Read 30 tweets
Guillan-Barré Syndrome (GBS) in ICU - a Tweetorial. #FOAMed #FOAMcc
First to note - is that there is no apparent association between GBS and #COVID19 #FOAMed #FOAMcc ucl.ac.uk/news/2020/dec/…
GBS is an ACUTE polyneuropathy (peripheral nervous system). Symmetrical in distribution. The onset is often over about 4 weeks and recovery often begins 2 weeks after progression has completed.
Read 35 tweets
👇👇 Live Thread for the great topics of #C19marathon, 22/05/2021 - #COVID #ICU @ESICM 👉👉 Watch the conference live here: esicm.org/events/lives-c… Image
Today, we'll be using the hashtag: #livesc19 for all content.
#livesc19 We'll kick off by looking at what went well and what we can do better together, accompanied by a global update on #COVID19. A focus on the science used to fight the pandemic and the successes/difficulties we had throughout the world. @DrMCecconi @msh_manu @strachanjamie
Read 70 tweets
So, remember C3,4,5 keeps you alive?!

Yes, today’s Tweetorial from @icmteaching, @ICUltrasonica and myself is all about the diaphragm!

It’s a pretty vital muscle, and a muscle often forgotten. It’s no wonder why, when it’s weak, your patients won’t liberate from the ventilator! Image
So, does #POCUS have a role in assessing it. Of course it does!🤷‍♂️😂

We use 3 probe positions:

1) Mid axillary/RUQ point - marker 12 O’clock
2) Mid clavicular/Subcostal - marker 12 O’clock
3) Mid clavicular/subcostal - marker 3 O’clock
Here’s MidAx/RUQ position:

The lung curtain does get in the way here, so run M-mode low down to catch the diaphragm.

We use the vital organ (liver or spleen) as our scan window and discriminator between chest cavity and abdominal cavity👍
Read 14 tweets
Today it’s Lung #POCUS for you!

It is:

Easy to perform
Accurate
Sensitive
Repeatable
Negates irradiation or transport elsewhere!

#FOAMed #POCUS #FOAMcc #foamus @icmteaching @ICUltrasonica

Where do we scan then?? Linear/curvilinear or phased probe positions shown👍👇
We don’t tend to use linear for the basal sections, as you need depth for the PLAPS points. To see the pleura clearly, minimise depth and drop gain down, you get a real concept of sliding on the screen.

Here are the normal views for you @GEHealthcare
Now; the Pneumothorax!

Pleural slide disappears as the parietal and visceral pleura separate. So, a static washing line is seen between the rib pillars 👇. The more you see, the more you recognise. Decompress IF your patient is compromised. It’s more sensitive than CXR!
Read 23 tweets
1/13

Today’s Tweetorial for you!

We look at basic cardiac #POCUS views👍 🫀

First; the Parasternal Long Axis (PLAX)

#FOAMed #FOAMcc #echofirst

Probe position shown with marker to right shoulder, left Parasternal edge; roughly at intercostal spaces 2-3/3-4🤷‍♂️
2/13

What should you see on ultrasound, and the associated sono anatomy🤔

BTW, this is the only basic position you need for this. Dipping the tail or lifting the tail then get you inflow and outflow views. This is more advanced. #FUSIC
3/13

Next, the Parasternal short axis (PSAX) - Mitral view

If you’ve lined up the aortic and mitral valves in the centre of the image on PLAX, a simple rotation of the probe through 90 degrees gives you your view🤛👍
Read 16 tweets
1/7

Here is a quick Tweetorial on Abdominal Aorta #POCUS for you all!

It’s a RULE IN study! Not a rule out ⚠️

Images from a forthcoming book chapter with @LukeFlower1 @icmteaching + @ICUltrasonica !

#FOAMed #FOAMcc #echofirst

#medtwitter

Hopefully we won’t see these?!
2/7

Apply careful firm pressure to displace pesky bowel gas. I start at the umbilicus; you can find the vertebral body easily here. You can then move up or down, tracing the vessel. The aim is to see as much of the vessel as you can. Marker - right (SAX) or to the head (LAX).
3/7

High Subxiphoid SAX

Find that vertebral body shadow again, you will see the aorta and IVC just above this. We are looking for the classic ‘seagull’ sign -

Hepatic artery and splenic artery = wings.

Coeliac trunk = body.
Read 7 tweets
So; there are often debates regarding ultrasound probe manoeuvres 🤷‍♂️

Here we go with a graphical Tweetorial, courtesy of myself, @ICUltrasonica and @icmteaching

Hope this helps (you may see these soon in a forthcoming book btw😉

#FOAMed #POCUS #FOAMcc #echofirst 1/7
2/7

SWEEPING

Here we slide the probe along a slug trail of gel, quite crudely, across a wide area of the body. This is often used to ‘window shop’, for structures we can’t see at first. When they snap into view, we can fine-tune movements 👍 Also allows view of larger organs.
3/7

ROCKING

Classic example here is when we get an apical view of the heart. At first, the heart may not be in line with the scan field. We can ‘swing’ it into view, so it appears more square on the screen. Makes parallel measurements more accurate and things less off-axis🤷‍♂️
Read 9 tweets
Finally found a PPE regimen that seems to work well. This is the Envo mask (envomask.com) and the Wiley-x SG-1 goggles (sporteyes.com/wiley-x-ssg-1.…). A few notes (thread): #medtwitter #FOAMcc #COVID19 Image
1. The goggles are not 100% sealed and have small vents along the sides. However, I do not think a 100% seal is necessary, and would be an incredible fog-creator. The Wileys are also pricey; consider these, almost as good (amazon.com/gp/product/B00…) but don't seal quite as well.
2. Any goggles, regardless of coating, will fog. Most important is a good mask seal, then use an anti-fog treatment. I found sprays to be a bother, but wipes are good. Try: sporteyes.com/hilco-fog-bust…
Read 5 tweets
#Ogitorial No35: hypothetical 41F #COVID19 intubated after failing NIV trial (24h).
A ETT 25cm
B SpO2 82% FiO2 1 Vt350 P12
❤️BP 110/80 HR 95, CapRef 1.5”
D avpU (propofol)
E Obese, no rash, soft abdomen
U bil B lines, RV=LV, EF~60%,
L pH 7.29, PCO2 35, Cr 1.4, Lactate 2.2 Hb10
Patient got remdesivir & dexamethasone. SpO2 88% after bolus NMB & pulling ETT(3cm). As you increase PEEP to 18, driving pressure improves, but the SpO2 drops to 72% without hypotension. You decrease PEEP back to previous but SpO2 still 70s. The next step is: #FOAMcc #MedTwitter
1/ With inhaled NO SpO2 improved to 97%, and after 2h FiO2 was down to 40% and rapid weaning.
Bubble study confirms suspected intermittent #PFO shunt which occurs in up to 19% #ARDS with ⬆️rescue Rx & ⬇️VFD
pubmed.ncbi.nlm.nih.gov/20601861/
pubmed.ncbi.nlm.nih.gov/33252722/
pubmed.ncbi.nlm.nih.gov/33150525/
Read 4 tweets
#SoMe on conferences should be more than 'just' posting photos of slides (that's where most of us started). It's about summarising, creating infographics like @FOAMecmo @WhistlingDixie4 @hughgifford #LIVES2020
and adding background infos, papers and other resources like @iceman_ex @aartisarwal @Gas_Craic
#LIVES2020
And creating excellent blogs and websites like criticalcarenorthampton.com by @Wilkinsonjonny or @_dasFOAM
#LIVES2020
Read 7 tweets
COVID-19: An EBM Take Part 2 at #ACOEP20

-Anticoagulation
-Awake Proning
-Invasive Mechanical Ventilation
-ECMO
-Hydroxychloroquine

#FOAMed #FOAMcc @ACOEP
Anticoagulation in #COVID19

-Admitted pts = weight based prophylaxis (unless contraindications)
-IMV = therapeutic anticoagulation
-Intermediate dosing has ZERO evidence base
-Thrombolysis --> Only if other indication (i.e. MI, PE, CVA)

#FOAMed #FOAMcc @ACOEP
Awake Proning in #COVID19

-Will not work on everyone
-Longer duration is better than shorter duration
-Pts require frequent assessments as they can become prone and O2 dependent (DO NOT ADMIT to Regular Floor)

#FOAMed #FOAMcc @ACOEP
Read 6 tweets
COVID-19: An EBM Take Part 1 at #ACOEP20

-When to Change Practice
-N95 Reuse
-Corticosteroids
-Remdesivir
-Convalescent Plasma

#FOAMed #FOAMcc
When to Change Practice

Expedited thirst for info & rapidity of pandemic lead to abbreviated peer review, publication of unvalidated data, retraction, and dissemination through press release

When to change = multidisciplinary discussion to set standard care at each institution
N95 Decontamination and Reuse

Make sure technique kills virus BUT doesn't affect filtration or fit
Best options: Vaporized H202, UV Light 260 - 285nm, or Time based strategy
2nd Best options: Autoclave 121C or Dry Heat 70C
Not an Option: 70% Ethanol
Read 7 tweets

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