@OnePagerICU

@OnePagerICU

Dr Gary Payinda

@GaryPayinda

@EMAJournal

A summary thread from the great Emergency Medicine Australasia issue I finally read on the plane; @EMAJournal #foamed

Thom study in EMA: patients with unstable cervical #fractures can sit (29%), walk (63%), lack midline tenderness (27%), and have delayed presentation (20%).

@EMAJournal

@EMAJournal #emergencymedicine

surf injuries were mostly lower c-spine

NEXUS underperformed compared to Canadian C-spine.

#drowning and cervical CTs are not inextricably linked: don't automatically image unless signs of axial loading/very specific concerns

@EMAJournal

@EMAJournal [my $0.02 on immobilising (virtually) anyone prehospitally: cervical immobilisation is a myth: collars don't actually immobilise, and 'immobilisation' doesn't actually prevent neurological injury...it *does* however harm (eg aspiration and other harms)]

Read 31 tweets

Jairo A. Cárdenas L.

@JCardenas_MD

@JCardenas_MD

🫁 Physics of lung US 🫁

#lungultrasound

#ICU #CriticalCare #IntensiveCare #IntensiveCarecommunity #FOAM #JCardenas_MD #MICU #CICU @JCardenas_MD

@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

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

Read 4 tweets

Joanna Poole 💙 (@jopo_dr@critcare.social)

@Jopo_dr

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

Read 16 tweets

Rachel Thee-in-pray-oon, MD, MSCS

@RThienprayoon

@jbogetz

Dr. Martin Bogetz, a bereaved father, sharing the legacy of his daughter Alyssa:
- an MSW who cared deeply about wellbeing
- the first non-physician associate program director in Peds at Stanford, who focused on supporting trainees
- sister of @jbogetz, #pedpc wonder ❤️ #hapc23

@AAHPM

The inaugural Alyssa Bogetz lecture: Dr. Susan Block talking about the state of integration of #hapc and #mentalhealth
Alyssa died of AN. The educational fund was started in her honor @AAHPM w the appreciation that our field needs to grow to support people like her. #hapc23

"I think it's a miracle how far we've come." - Dr. Susan Block

We are the 6th largest subspecialty of the largest specialty in the US! #hapc #pedpc #hapc23

Read 10 tweets

Syed Shahrul Naz

@drshahrul80

“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

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

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.

Read 4 tweets

Jim Jackson

@jcjackson68

I often discuss Post Intensive Care Syndrome on Twitter - called "PICS" but what is it? Let's briefly unpack it in a 🧵 1/7

@DrDaleNeedham

Coined by a thoughtful clinician, pioneering researcher, and winsome colleague @DrDaleNeedham in 2012 in an article that has been cited over 2,000 times. It refers to a condition that affects millions of survivors of critical illness/intensive care. @CIBScenter 2/7

PICS is a phenomenon in which individuals develop new or worsening symptoms/difficulties after the #ICU in one or more of 3 key domains - cognitive, psychological, physical. 3/7.

Read 7 tweets

Jim Jackson

@jcjackson68

@CIBScenter

🧵We often refer our patients for "neuropsychological" testing but what exactly is it, do you need it, and how does it add value? A thread. 1/10 @CIBScenter

Neuropsychological testing - also known as cognitive testing - aims to provide a comprehensive look at key areas of your cognitive functioning - aspects of your memory, attention, processing speed, executive functioning and more. It is a "deep dive." 2/10

@CIBScenter

Neuropsychological testing contrasts with cognitive screening (CS). Often 5 or 10 or so minutes in length. CS has a valuable place and a role to play but it provides a brief glimpse, has limitations especially in mild cases, and is not diagnostic. @CIBScenter 3/10

Read 9 tweets

Nida Qadir, MD

@NidaQadirMD

So this has been making the rounds. I realize it’s probably meant to be a thought experiment & deliberately provocative, but still, philosophical arguments should be rooted in at least some amount of reality.

I will now rage tweet about everything wrong w/ this concept. Enjoy🧵

Let’s start w/ the author’s premise: if we’re ok w/ #organdonation after brain death, then we should be ok w/ “whole body gestational donation” (WBGD).

Even putting aside the part about this sounding like a horrifying, dystopian baby farm, they’re not even remotely comparable.

Here’s why:

#Organdonation after brain death typically happens very quickly (a few days or less). This is not simply because we’re uncomfortable keeping someone’s organs alive longer; it’s because it’s incredibly challenging & often not possible, despite the authors assertions

Read 21 tweets

Jim Jackson

@jcjackson68

@CIBScenter

🧵We've been leading support groups for #ICU survivors for nearly 10 years (over 2 years with #LongCovid patients). Across literally thousands of patient encounters, what have we learned? I'll unpack these insights in tweets to follow. Thanks for reading them. @CIBScenter 1/10

To begin, the ROI for support groups is enormous- they require minimal expenses, utilize few resources, allow you to touch the lives of sometimes dozens of people at the same time, and contribute to changed lives. An inexpensive way to make a big impact. 2/10

They require competent leaders who understand group processes. You can find such people or you can become one but make sure that for at least one group leader, this is not their "first rodeo." We don't all have to be experts but we owe members that much. 3/10

Read 10 tweets

Jim Jackson

@jcjackson68

PTSD is a common phenomenon in ICU survivors, impacting literally millions of people around the world, every year. What do we know about it? A 🧵 1/5

In the late 1990s, research on #PTSD after the #ICU first emerged, with early studies suggesting prevalence rates of 40 to 50 percent, far higher than in combat veterans and other high risk groups. Studies since then have documented rates of 10% to 20% - clearly a problem. 2/5

@CIBScenter

Risk factors for PTSD in ICU survivors vary but include female sex, young age, a history of delirium, and a history of psychiatric illness. The presence of delusional memories also plays a role. @CIBScenter 3/5

Read 5 tweets

Paul Wischmeyer MD ⎪ #NutritionMatters 💪

@Paul_Wischmeyer

@NEJM

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
#SCCMSoMe #FOAMed

@NEJM

2/3 12 Key ICU TRIALS I teach each week

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
#FOAMcc #ICU

@NEJM

💥 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

Dr. Lyne Filiatrault

@DrFiliatrault

@shazmamithani

A good read from @shazmamithani
thestar.com/opinion/contri… via @torontostar

"Every Canadian needs access to a family doctor. Governments need to step up and commit to doing what’s right for the system, instead of focusing on Band-Aid solutions."

"We need a true understanding that the best patient care is care in the community, and that in part, hospitalization for preventable illness is a failure."
I'd had we need a culture change from within and from outside healthcare.

Read 8 tweets

Pankti Mehta

@PanktiMehta24

It's 🥶 & we're coming across many cases of peripheral ischemia/gangrene

🔢The semiology of seizures is what we are all taught, but gangrene is another condition where history is the king 👑

🔁It's essentially a demand≠supply mismatch

#MedEd #MedTwitter #RheumTwitter

The 📝 goes on & so that we can save ⏳ & 💰 on the tests, I like to broadly divide the pathology into:

1️⃣Luminal: atherothrombosis, thrombosis (APLA, DIC), cryofibrinogenemia

2️⃣Vessel wall: vasculitis (ANCA, PAN, SLE),vasculopathy (scleroderma spectrum)

3️⃣External compression

Q1️⃣: How was the onset?

🐌Insidious onset, gradual progression is the most common

➡️peripheral vascular disease

➡️most vasculitides

➡️vasculopathy

#MedEd #MedTwitter

Read 12 tweets

Dr Sudhir Kumar MD DM🇮🇳

@hyderabaddoctor

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.

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

Read 5 tweets

Jiang Jiang (JJ)

@JiangJiang43

There is a decline in emergency & critical care peaks in #China's large cities, while small & medium-sized cities & rural areas will soon experience peaks in emergency & critical care, said Jiao Yahui, an official with the National Health Commission in a recent interview. 1/6

There will not necessarily be an increase in #COVID infections during Spring Festival. Still, there may be increase in emergency&serious illnesses in small&medium-sized cities&rural areas, Jiao noted, saying that infection rates have reached a certain level in these regions 2/6

Jiao said that "from the typing of clinical cases of #omicron in #China in 2022, the proportion of pneumonia in the common type of COVID-led illnesses is relatively low, less than 10%, which is about 8%." 3/6

Read 7 tweets

ICU Advantage

@ICUAdvantage

The Swan-Ganz Catheter 🦢🫀

AKA, the Pulmonary Artery Catheter or PA Catheter.

A thread discussing the basics of our PA Cath:
#MedTwitter #FOAMed #ICU

The PA Cath is a specialized venous catheter that can give us a whole host of values related to cardiac function, hemodynamics, and perfusion. 🧐

This cath is a long balloon tipped cath that enters the venous system. It is passed into the RA, through the tricuspid valve, into the RV, and then finally through the pulmonic valve with the tip resting in the pulmonary artery (PA). 🫀

Read 11 tweets

Osler

@oslertech

@CICMANZ

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

osler.app.link/CztXIRjyntb

If you're new to mechanical ventilation, this will give you the basics

osler.app.link/dnoTmYYRkvb

#mechanicalventilation

Read 12 tweets

Dr Sudhir Kumar MD DM🇮🇳

@hyderabaddoctor

#Valproate (VPT) is still more efficacious and more cost-effective as compared to #levetiracetam (LEV) for treating generalized #Epilepsy (GE)

1. I see an increasing trend for prescribing LEV in emergency room, ICU & OPD for GE
#MedTwitter #neurotwitter

doi.org/10.1016%2FS014…

2. In a recent study, LEV was found to be inferior for times to treatment failure, 2-year remission from seizures, and first subsequent seizure. In addition, LEV was not found to be a cost-effective alternative.

3. This is despite the fact the LEV is associated with a higher incidence of #psychiatric and #behavioral adverse effects.
This is a major problem in #ICU patients, as it adds to the burden of patients with #psychosis in ICU.

Read 5 tweets

Fluid Academy

@Fluid_Academy

@avkwong

Do we need maintenance fluids at all? What is your preferred maintenance solution?
#IFAD2022 #FOAMed #FOAMcc

REPOSITORY: whova.com/portal/webapp/…
REGISTER: whova.com/portal/registr…

@avkwong - @Manu_Malbrain - @FOAMecmo - @Wilkinsonjonny - @strachanjamie - @Drnasap - @iceman_ex

@avkwong

When do you use starch solutions?
#IFAD2022 #FOAMed #FOAMcc

REPOSITORY: whova.com/portal/webapp/…
REGISTER: whova.com/portal/registr…

@avkwong - @Manu_Malbrain - @FOAMecmo - @Wilkinsonjonny - @strachanjamie - @Drnasap - @iceman_ex

@avkwong

When do you use (hypotonic) albumin 4% solutions?
#IFAD2022 #FOAMed #FOAMcc

REPOSITORY: whova.com/portal/webapp/…
REGISTER: whova.com/portal/registr…

@avkwong - @Manu_Malbrain - @FOAMecmo - @Wilkinsonjonny - @strachanjamie - @Drnasap - @iceman_ex

Read 33 tweets

Jordan Holloway, MD (she/her)

@jholloway_MD

@tammamtu

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

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.

Read 16 tweets

Jordan Holloway, MD (she/her)

@jholloway_MD

@akhadilkarMD

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

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.

Read 14 tweets

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