Discover and read the best of Twitter Threads about #foamcc

Most recents (24)

ICU/CCU/Pharmacy pearls: Adenosine is another one of my favorite drugs (again: no COI); who doesn’t want to walk into a patient’s ward room after a rapid response is called for a HR of 190/min, administer 6 mg of adenosine and head back to the ICU 10 min later leaving the patient
on SR 80/min and the ICU charge nurse relieved that she will not have to find a creative way to “open up” another ICU room. Adenosine push is one of the VERY FEW intensivists’ triumphant moves, so I will take it. Nevertheless, there are a few things about adenosine use
that I think are fun or good to know (there are probably more than few, I just don't know them!):
1. Adenosine is a natural substance formed by the degradation of adenosine triphosphate (ATP); yes, that ATP! So, in theory
Read 14 tweets
Al parecer Emmanuel Rivers tenía conflicto de interés en su estudio de EGDT, en 1997 había mandado a la oficina de patentes de 🇺🇸 un dispositivo para medir SvO2 continua (🧵 1/4) #FOAM #FOAMcc #sepsis #Emergency
Sus metas tempranas como sabemos consistían entre otras en mantener una SvO2>70 (con monitoreo continuo🧐) ya sea con líquidos inotrópicos o hemoderivados, excluyeron 27 pac 13 del grupo EGDT y 14 del grupo control porque “no completaron 6 hrs” (2/4)
Sus resultados fueron biológicamente improbables, el perfil hemodinámico de SvO2⬇️ con TAM⬆️ en sus datos basales es atípico para sepsis, casi todos los sépticos tienen SvO2 ⬆️ (3/4)
Read 4 tweets
Here’s a fun ICU riddle - why do these two different patients both have funny colored effluent in their CRRT bags?


1/ ImageImage
One patient received methylene blue (causing green urine & effluent) and the other received hydroxycobalamin (causing dark red urine & effluent).

But what do these two cases have in common?

2/ ImageImageImageImage
The explanation is that both of these patients had vasopressor refractory shock.

Both methylene blue and hydrocobalamin can be used for refractory distributive shock.

Methylene blue…


But why?
Read 15 tweets
Important lessons 📜 from ICU case:

🚨Not everything is septic shock
🚨A limited echo has limitations

Older patient in shock on 3 vasopressors, who initially presented with dyspnea and a CXR like 👇

What the diagnosis?


Image credit:…
Presented to the ED with acute onset dyspnea, new O2 requirement 6 L NC, minimal PMH

BP 95/70, HR ~ 100, afebrile

Hypoxemia worsened during ED stay requiring intubation

Now hypotensive

CT obtained with unilateral right sided pulm infiltrates, small pleural effusions, no PE
Labs 🧪

WBC 20k

Troponin mild elevation

Lactic acid 5.0

Cr mild elevation

U/A with > 50 WBC

Antibiotics, 2 L IVF given and admitted to ICU
Read 8 tweets
Another #CriticalCare #Tweetorial!

🫀Left Ventricular Assist Device for the non-cardiologist🫀

Join me on a journey through LVADs with some #FOAMcc highlights useful for #CritCare #EmergencyMedicine #HospitalMedicine #Meded

@CardioNerds @emoryheart
Goals for this #Tweetorial
1-Review the basics of what an LVAD is and does
2-Discuss indications for an LVAD
3-Review some common complications of the device itself
4-Review systemic complications of an LVAD

Lets start with some basics of the LVAD. Historically the two most commonly encountered are the Heartmate 3 and the Heartware.

We will focus on the Heartmate 3 (Shown below)

Read 23 tweets
ICU stories: You start your night shift and while walking in and out each patient’s room, you see this 👇 on one ventilator's screen:
The patient (I know: I should have looked at the patient first, not at the ventilator screen... 🤷‍♂️) is breathing like this 😳:
Quick chart review: middle-aged pt admitted w ARDS > 1 month ago. Already w tracheostomy + PEG. Still unable to be weaned on trach mask, despite being on "moderate" fio2 of 40-50%. On iv sedation; drowsy, hemodynamically stable. Not febrile or acidotic. No "weird" labs. CXR:
Read 20 tweets
Here’s a situation many of us have seen in the ICU or ED: “It looked like there was ST elevation on the monitor but when I took a 12 lead it was gone?!”

A STEMI went MIA? Here’s a #tweetorial all about why ST segments look different on monitors.

1/ ImageImage
First, here’s another great example of "disappearing ST elevation", from Dr. Smith’s ECG Blog @smithECGBlog

(If you don’t already you should definitely follow Dr Smith & bookmark his site; IMO it's the best site for ECGs; you can thank me later)
2/ Image
In order to understand *WHY* the ST segment looks different, we need to know how an ECG works & understand just a little bit of electronics & math.
(Don't worry, I promise no equations or circuit diagrams 🤞)
Read 18 tweets
A patient suffers STEMI causing biventricular failure, including severe RV infarct. An Impella is placed, and they arrive in the ICU from the cath lab. You see the following. (This arterial line is functioning.)

What do you know about the hemodynamics? 🧵

#FOAMcc #medtwitter
In this case, the Impella is completely decompressing the LV and taking over its output. There is NO pulsatility to the arterial flow — only laminar flow from the Impella. Can you think of any implications of this for the immediate resuscitation?

#FOAMed #cardiotwitter
1. PULSE oximetry will not function. Absorption or reflection oximetry relies on detecting pulsatility to differentiate arterial blood from other blood and tissues (that’s why it gives you a pleth). You will need to rely on blood gases.
Read 9 tweets
When flow dyssynchrony occurs in VC modes, the first reaction is often to increase the flow rate. Reasonable… but it often fails! Why? Maybe because any fixed (or fixed decelerating) flow can have trouble matching the patient effort at all stages of inspiration. Example:
Here the flow starvation occurs in the latter part of the breath, not the start, creating a biphasic appearance to the flow curve. What if we simply increase the flow?
It’s no better! Now flow is probably too high at the start (initial flow overshoot as evidenced by the steep pressure spike)… but still inadequate at the end. Also, the pressure spike and resulting short I-time contributes to some double triggers.
Read 4 tweets
Severe Abd pain, n/v, & distention. BP 96/50, HR 124. No bowel sounds. Diffuse tenderness. WBC 17.9. Lactate 3.8. POCUS shown. #POCUS #FOAMed #FOAMus #FOAMcc #MedEd #EMBound @ACEP_EUS @PhilipsPOCUS @MetroHealth_EM @MH_EMultrasound @NephroP @jminardi21 @kyliebaker888 @TomJelic
Dx: Complicated SBO. Meets SBO criteria with diameter > 2.5 cm greater than 10 cm in length. Also has absence of peristalsis and adjacent free fluid--concerning for complicated SBO
Read 8 tweets
ICU stories: Middle-aged pt w PMHx of rheum fever/A fib underwent MV+AV replacement, TV repair w ring, Maze procedure + LA appendage closure. At the end of surgery, TEE was “fine”; pt was transferred to the ICU intubated (fio2 40%) on low-dose levo (0.04). Could not be extubated
because few h later, lactate began to ⬆️ and ivf were given. Levo gtt did not ⬆️ much (just @ 0.1 next am) but lactate was up to 17 mmol/l & pH was 6.98. I was told that pt was probably still "under-resuscitated". When I 👀the chart, pt had received multiple NS, bicarb & albumin
boluses and was > 8 liters positive. I first pulled the bed sheets to look at the legs and feel the skin temp:
Read 22 tweets
Do we need maintenance fluids at all? What is your preferred maintenance fluid solution?
#IFAD2021 #FOAMed #FOAMcc

REPOSITORY (access 100+ lectures):…

@avkwong - @Manu_Malbrain - @azJanPalfijn - @FOAMecmo - @Wilkinsonjonny - @strachanjamie - @iceman_ex
When do you use (hypotonic) albumin 4% solutions?

#IFAD2021 #FOAMed #FOAMcc
REPOSITORY (access 100+ lectures):…
@avkwong - @Manu_Malbrain - @azJanPalfijn - @FOAMecmo - @Wilkinsonjonny - @strachanjamie - @iceman_ex - @icmteaching - @Gas_Craic
Read 30 tweets
Thanks so much @avkwong and @Manu_Malbrain for their concise and powerful talks on the dangers of fluid overload (or better named fluid accumulation syndrome) - associated with death, affecting every organ system. #IFAD2021 #FOAMed #FOAMcc
Infographic via @hughgifford Image
Keep in mind the deleterious effects of fluid overload and fluid accumulation syndrome on cardiovascular function #IFAD2021 via @Manu_Malbrain
@azJanPalfijn Image
Keep in mind the deleterious effects of fluid overload and fluid accumulation syndrome on renal function #IFAD2021 via @Manu_Malbrain @azJanPalfijn Image
Read 7 tweets
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!

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
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)

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

⏱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

Read 5 tweets
ICU stories (this story includes the answer to the quiz from yesterday): Young pt w PMH of HTN/HLD/DM2/CAD (stent of obtuse marginal) presented with chest/abd pain, N/V. Stat EKG (infero-lateral "changes"; ST elevation in inferior leads?): Image
Emergent cath: "diffusely diseased LAD w stenosis 40%, non-dominant Cx with diffuse disease and stenosis <40%, widely patent OM stent, dominant RCA w diffuse disease and stenosis 50%. Pt did not have hemodynamically significant stenosis to explain symptoms and was admitted to CCU
... on nitro drip (for BP control). Next am, pt went into a wide-complex tachycardia that deteriorated in seconds to V fib. CPR started. Defib x1 back to SR. The post-ROSC ECG (that I posted yesterday) showed: Image
Read 28 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


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
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: and the thread 👇 #FOAMcc #FOAMecmo

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.

🔗 #FOAMcc #FOAMecmo

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.

🔗… #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.
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.… (Dr J Yeung rID: 13415)
Read 22 tweets

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