Discover and read the best of Twitter Threads about #IMPOCUS

Most recents (24)

#Nephrology #POCUS short story:
1/ Simple case, want to remind some pitfalls in routine practice.
There was a patient with orthostatic hypotension. Likely neurogenic secondary to amyloidosis.
Read the thread ๐Ÿงตbelow:
#IMPOCUS #MedEd mini #tweetorial
2/ Physician A orders IV albumin q 6 hours and keeps continuing because:
1. 'Formal' echo from 4 days ago reported a RAP of 3 mmHg = not high
2. 'Documented' weight showed 3 kg drop since admission
Interestingly, documented cumulative fluid balance is +4 L!
3/ Physician B comes in and performs physical examination (#POCUS). Supine BP is relatively low (SBP ~103 mmHg) but nothing different compared to patient-reported figures at home. Pt feels OK, on midodrine.
Here is the IVC๐Ÿ‘‡
Read 9 tweets
OK #VExUS #POCUS enthusiasts, time for another case discussion.
Somebody asked if I ever recommend IV fluid in a patient with #VExUS 3.
Here is one example where I did.
1/ First, let's see the #physicalexam (#IMPOCUS) findings, then will tell about the case. #MedEd #Nephrology
2/ So, hepatic shows D-only pattern๐Ÿ‘†
If we are doing #VExUS, IVC must be big. Here is the M-mode #POCUS ๐Ÿ‘‡
3/ Renal parenchymal vein #VExUS #POCUS
It also demonstrates D-only pattern ๐Ÿ‘‡
Read 15 tweets
#POCUS quiz of the day:
Easy one. Identify 1, 2 and 3.
POLL in thread ๐Ÿ‘‡ #IMPOCUS #MedEd
PE = pleural effusion
PER = pericardial effusion
Ao = aorta
IVC = inferior vena cava
Rt = right
Lt = left
Correct answer: option 2 -
1. left pleural effusion (note the appearance of collapsed lung; also u can see rib shadows/posterior chest wall = lung area)
2. Right pleural effusion (remember the Boomerang sign on subxiphoid view?)
3. IVC
Read 4 tweets
1/ Basic #CadiacUS models (color coded / labeled) for Educators or Beginners

At least 2 options when learning any #IMPOCUS โ€“ memorize or ๐—ฐ๐—ผ๐—ป๐—ฐ๐—ฒ๐—ฝ๐˜๐˜‚๐—ฎ๐—น๐—ถ๐˜‡๐—ฒ.

Both will get you there but IMO the latter allows for taking next step into advanced imagingโ€ฆ
2/ This is especially true in Cardiac POCUS โ€“ 4 basic views, but actually so many more. #ECHOFirst

Firm understanding of anatomy and spatial relationships is key!

โžฃNote axis of the heart
โžฃ๐—ฅ๐—ฉ the most ๐—ฎ๐—ป๐˜๐—ฒ๐—ฟ๐—ถ๐—ผ๐—ฟ structure
โžฃ๐—Ÿ๐—” the most ๐—ฝ๐—ผ๐˜€๐˜๐—ฒ๐—ฟ๐—ถ๐—ผ๐—ฟ
3/ #PLAx is ๐™๐™ƒ๐™€ view to learn, if any

Major chambers in view
Read 9 tweets
#Nephrology #POCUS case of the day:
What do you think is this anechoic structure adjacent to liver?
See thread ๐Ÿ‘‡ for the answer and more images. #MedEd #IMPOCUS
Let's start with a poll before seeing other images: โ˜๏ธ? #POCUS
The answer is right renal cyst. Note how the kidney appears with fanning the probe. #POCUS
Is rest of the kidney normal? doesn't appear to be...๐Ÿค”
Read 11 tweets
Renal #POCUS in a #dialysis patient: Looks fine at first glance (thin parenchyma as expected) but fanning anteriorly reveals a large cyst, which would have been missed otherwise. Labeled images and notes in thread ๐Ÿ‘‡
#Nephrology #MedEd #IMPOCUS
Labeled first image #POCUS
Note: peri-renal fat (usually prominent in ESRD patients) can be confused with free fluid.
Labeled second image #POCUS (obtained with phased array probe)
Note: EKG is not needed ๐Ÿ˜€
Read 5 tweets
Known distal UVJ stone. Has new rt flank pain. Mild hydro but what else? #POCUS #IMPOCUS #FOAMed #FOAMus #MedEd #MedTwitter @ACEP_EUS @SeeWithSound @PhilipsPOCUS @IMPOCUSFocus @medpedshosp @NephroP @jminardi21 @HeyDrNik @TomJelic @cianmcdermott @MH_EMultrasound @thepocusatlas
Area of increased echogenicity of parenchyma seen in upper pole. @Manoj_Wickram @tomkehrl @MH_EMultrasound @MetroHealth_EM @Casscln @ria_dancel @cm_lopresti @DRsonosRD
Also has trace perinephric fluid seen (arrow)
Read 17 tweets
A tweetorial on optimal machine settings for B line image acquisition, with a focus on: focal position at pleura, harmonics off, and increased far gain.

Inspired/based on the recent article -โ€ฆ
@cameron_baston @IsaacMatthiasM1


Let's start with some polls
We will stick to low frequency probes here (i.e. curvilinear and phased array - linear has its own purpose for detailed pleural assessment)

Which preset do you prefer for B line assessment?

What depth do you typically set?

Read 19 tweets
Thread: Ultrasound for CVC placement - more than just follow the needle tip and confirm the wire.

There are many potential uses of ultrasound during CVC placement, shown here. Not all are essential.

Lung sliding on ipsilateral side - for a comparison to post-procedure
-use linear probe
-apical and lateral/anterior
Check vessel
-confirm compressibility
-understand axis of vessel
-check prox and distal for stenoses
-optimize depth and gain (this image may be undergained)
Read 25 tweets
Understanding #VExUS from scratch:
A mini #tweetorial on normal hepatic vein waveform genesis ๐Ÿ‘‡ #MedEd #echofirst

1/ Understanding color and direction
2/ What is S wave? #POCUS
3/ V wave #POCUS
Read 8 tweets
#POCUS #echofirst The correct answer is dilated coronary sinus [48% got it right (of 229 votes)]. From #IMPOCUS standpoint, 2 main causes: persistent left superior vena cava and pulmonary HTN. This pt had the former. Normal anatomy of the coronary sinus (Read #thread)๐Ÿ‘‡ #MedEd
More anatomy: 3D CT angio
We need to understand the anatomy first to understand #pocus orientation
Original image shows the typical location of CS in PLAX view. Don't confuse with descending aorta. You can also see CS from the apical window. From apical 4C, tilt the transducer posterior (in the opposite direction as you would for the 5-chamber view) #POCUS
Read 7 tweets
Differentiating portal venous gas from pneumobilia on ultrasound. See thread. #POCUS #FOAMus #FOAMed #IMPOCUS #MedEd #MedTwitter #ultrasound @ACEP_EUS @USIGcleveland @MetroHealth_EM @aedrake65
Case 1. Liver TRV sweep. Which is present? Answer poll.
Case 1. Which is present?
Read 9 tweets
Pt-Bilat LE pain/swelling 5 days.Prior hx of unprovoked DVT/PE years ago but off meds due to insurance. See thread. POCUS DVT #POCUS #IMPOCUS #FOAMed #FOAMus #MedEd #FOAMcc @ACEP_EUS @medpedshosp @cianmcdermott @jminardi21 @grepmeded @siddharth_dugar @msiuba @NephroP @SonoStache
What POCUS DVT protocol to use? 2-point or 3-point or extended? With or without Doppler? Meta-analysis showed good performance of 2 and 3 point POCUS but need to understand POCUS compression limitations if only compression used:โ€ฆ
Adhikari and colleague article showed 6.3% false neg rate due to prox isolated DVT with 2-point compression. Limitations of POCUS prox compression DVT exam go beyond just missing isolated/focal DVT.
Read 9 tweets
#POCUS Here is the "story of Foley" #tweetorial about diagnosing misplaced Foley catheter using #IMPOCUS #MedEd #nephrology

1. Normal urinary bladder ๐Ÿ‘‡
2. Urinary bladder decompressed by Foley catheter. As the Foley balloon is filled with water, it appears as a well-defined cystic structure on #POCUS
Asterisk (*) indicates the tiny bit of urine around the balloon.
3. The sonographic image demonstrates the transverse view of the bladder distended with urine(*) despite having a Foley in place. Indicates obstruction of the catheter by a blood clot or debris. Treatment is to flush the catheter, not page #nephrology for dialysis! ๐Ÿค
Read 9 tweets
Patient with RUQ abdominal pain. Difficulty finding GB. Pt denies history of prior abdominal surgery and no scars seen. See thread. #POCUS #IMPOCUS #FOAMed #FOAMus #MedEd #MedStudentTwitter @medpedshosp @NephroP @grepmeded @cianmcdermott @ACEP_EUS @PhilipsPOCUS
GB Sag and TRV sweeps. GB not seen. No surgical clips seen. Contracted GB, agenesis of GB, ectopic location of GB, prior removal (and patient forgot--it does happen)?
On Sag image, don't confuse bowel contents with GB filled with sludge
Read 6 tweets
Another #VExUS #POCUS case: Pt with advanced kidney disease and volume overload. Note progressive decongestion with ultrafiltration. IVC was >2cm all through. Mild TR. Great way to monitor the efficacy of decongestive therapy #IMPOCUS #MedEd (Normal-abnormal flashcards in thread)
Normal -> abnormal hepatic vein #Doppler #POCUS with increasing congestion. Note D-wave is the only one below the baseline in severe congestion.
Normal -> abnormal portal vein waveform #Doppler #POCUS with increasing congestion. Note the to and fro motion with severe congestion as seen in our patient at presentation.
Read 4 tweets
The answer is right pleural effusion #POCUS #IMPOCUS
<30% got it right = warrants a mini #tweetorial about pleural effusions on #echofirst
1/ Let's see the anatomic correlate of PSAX to get a better idea ๐Ÿ‘‡ #MedEd
2/ those who said left pleural effusion probably had PLAX view in mind #POCUS This one is actually left pleural effusion ๐Ÿ‘‡ [I'm sure you know descending aorta is an anatomic landmark that differentiates pericardial (anterior) and pleural (posterior) effusions]
3/ The source of confusion could be the direction of the probe marker, which corresponds to orientation marker on the screen ['Logiq P9' in this case].
It's towards right shoulder to obtain PLAX view and to the left to obtain PSAX (lt & rt hips in ER convention). ๐Ÿ‘‡#POCUS
Read 8 tweets
Now that we have several #VExUS #POCUS resources from different educators, I'm going to put them together as a thread and pin to my profile #IMPOCUS #FOAMed
1/ Recent case showing improvement in Doppler indices (helped guiding decongestive therapy in a pt. with minimal symptoms)
2/ What is included in venous excess grading by ultrasound? Landmark paper by @WBeaubien @ThinkingCC @khaycock2 @EMNerd_ @Ad12Andre et al.โ€ฆ
Read 12 tweets
Time to follow up on #VExUS #POCUS
Today's images will demonstrate the improvement in congestion with IV diuretic therapy.
1/ Portal vein - note the pulsatility is ~55% (<30% taken as normal) & the whole waveform is above the baseline now = improvement!! #IMPOCUS
2/ Also note the RAP meter in the above image with arrow pointing to current state.
Below is the side-by-side comparison between the initial #POCUS image and the current one.
3/ Hepatic vein waveform: Note the improvement; arrow points to current state on the RAP meter. #POCUS @ThinkingCC @ArgaizR feel free to comment if you don't agree with the labeling.
Read 10 tweets
Break from difficult cases but the #VExUS #POCUS series continues....this time #heartfailure with classic images.
1/ Pulsatile portal v - 100% pulsatility in this case with bidirectional flow. Note the waveform change (on top) with โฌ†๏ธ RAP (Tang. et al 2016) #IMPOCUS
2/ How does the normal portal vein Doppler #POCUS look like? - above the baseline (flow towards the transducer) and gently undulates. Like this ๐Ÿ‘‡
3/ Here is the hepatic vein waveform from our #heartfailure patient. Looks biphasic indicating severe congestion like that of portal vein. #POCUS
Note the RAP meter on top from Tang, et al. again.
Read 10 tweets
Simple-appearing #IMPOCUS scenario but important!
1/ Consulted for AKI. Patient: Middle-aged gentleman with significant peripheral edema.
Plan: Let's try diuretic
Oh, may be perform #POCUS
-> IVC looks plump, doesn't appear to collapse ๐Ÿ‘‡ = needs diuretic. #MedEd
2/ but the renal attending likes to do #VExUS
Let's look at portal vein #POCUS
-> Looks great, doesn't seem to indicate congestion
3/ What about the renal vein #POCUS?
Not a great picture due to breathing but seems the waveform is continuous (appears noisy because the gain was increased intentionally) [don't pay attention to RI - its inaccurate]
Read 8 tweets
What is the anechoic tubular structure? - IVC with a catheter or something else ๐Ÿค”
Clue: @PittIMPOCUS recently shared a similar image.
Answer: In thread #POCUS #IMPOCUS #FOAMed
That's duodenum with a feeding tube #POCUS
Anatomic image๐Ÿ‘‡showing the relationship between liver & the duodenum (courtesy: Gray's anatomy)
Here is the #XRAY demonstrating the tube in duodenum
Read 4 tweets
One of the key advantages of doing #POCUS is we know when to avoid unnecessary/ 'empiric' iv fluid administration. Almost every organ suffers from the pathologic sequelae of fluid overload. Take a look here in this thread ๐Ÿ‘‡ #IMPOCUS #MedEd
*Note B-lines on #POCUS can detect asymptomatic lung congestion
Read 10 tweets
Short image tweetorial on thoracic ultrasound findings in pneumonia. #POCUS #IMPOCUS #FOAMed #FOAMus #Medtwitter #Meded #COVID19 @medpedshosp @cianmcdermott @msiuba @siddharth_dugar @grepmeded @NephroP @emresidents
Normal lung ultrasound. A-profile with thin pleural line with lung sliding. Linear transducer used.
Irregular pleural line with patchy B-lines. Seen in viral (including COVID19) and bacterial pneumonia. This patient had mycoplasma pneumonia. Linear probe used.
Read 11 tweets

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