Discover and read the best of Twitter Threads about #foamus
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ICU pictorials: A patient was admitted for "weakness". Unimpressive vitals / phys exam / labs. A few days later because of temp 101 F, a fever w/u was initiated. Due to "SOB", a CT chest angio was done:
👆Massive saddle PE extending in both sides w evidence of R heart strain 
Echo findings:
ICU stories (last night): A patient had been admitted w pneumonia / intubated / on norepi 0.12. At 01:00 am, the nurse notifies you that urine output is 5-10 cc/hr for the previous 3 hours. BP is 99/44, HR 90, CRT 3 sec. You take the US in patient's room to see what's happening.
What POCUS finding(s) is/are likely to explain the oligo-anuria in the shortest amount of time?
If you (and the patient) are lucky, you may find this:
ICU stories (a brief one): 60 yo male w lung cancer / CAD / HTN / HLD / status post chemotherapy a month ago presented to the ED w SOB/cough/weakness after failing outpatient tx w azithromycin. CT chest: no PE but positive for bilateral consolidations:
Patient came to the ICU intubated, sedated, on pressors & antibiotics for PNA. Next step: POCUS. PLAX looked "weird", so Doppler and "zoomed" views were recorded:
PSAX & subcostal views:
ICU stories (from the trenches): 70 yo pt w hx of A-fib/CAD/ICM w EF 25%/VT ablation s/p BiV ICD/CKD/HTN/HLD/peripheral vasc dz/COPD etc presented to outside 🏥 w SOB/weakness/falls. Labs: wbc 15k/creat 3.5 (baseline 2.0)/INR: 8.5/AST/ALT/Tbil: 180/250/3.0, lactate 3.5
RUQ US was obtained to work-up elevated LFTs:
Diagnosed w bilateral PNA/AKI/liver dysfunction. Treated for sepsis w ivf boluses, broad-spectrum antibiotics, steroids, bicarb. Continue to get worse; due to ⬆️O2 needs, transferred to our 🏥. I saw her the next am: in resp distress while on BiPAP 15/10-100%, abg 7.26/50/70/19.
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...)
I just read this 👇 in the Comprehensive Critical Care: Adult, 3rd Edition; 2022 (@SCCM book). Are we still targeting CVP > 8?
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...
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.
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.
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:
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
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
CCUS (complete compression US), includes compression US from the common femoral vein to the ankle
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
Technology changing the ultrasound game #WINFOCUS22 #EACEM22
First up - machine learning and artificial intelligence - the use of automation
First up - machine learning and artificial intelligence - the use of automation
There are a number of manufacturers now with automated tools
- B lines
- VTI
- IVC
Do colleagues use them routinely??
#WINFOCUS22 #EACEM22
- B lines
- VTI
- IVC
Do colleagues use them routinely??
#WINFOCUS22 #EACEM22
It is not just measurements though - can the software/machine help make POCUS more accessible. Act as a teacher?
I think so.
#WINFOCUS22 #EACEM22
I think so.
#WINFOCUS22 #EACEM22
Are you a #juniordoctor or #medstudent?
Here's 10 great FREE modules to help get you started on the wards!
#meded #medschool #tipsfornewdocs #juniordocs #FOAMed #medtwitter #medstudenttwitter #juniordoctors #medstudents
Here's 10 great FREE modules to help get you started on the wards!
#meded #medschool #tipsfornewdocs #juniordocs #FOAMed #medtwitter #medstudenttwitter #juniordoctors #medstudents
Occasionally you'll need to perform sterile procedures. Make sure you prepare the best you can
osler.app.link/CztXIRjyntb
osler.app.link/CztXIRjyntb
Providing basic life support is a core skill for all healthcare staff
osler.app.link/u4fe8uqyntb
#basiclifesupport #bls #FOAMresus #resuscitation
osler.app.link/u4fe8uqyntb
#basiclifesupport #bls #FOAMresus #resuscitation
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:
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:
ICU POCUS snippets: A bit of context: An elderly patient with hx of DM2 / HTN / HLD / peripheral vascular disease / ureteral stent & recurrent UTIs is admitted to the hospitalists’ service w diffuse abdominal pain, nausea & vomiting. Treated for a few days w antibiotics...
...but never really felt any better (weak/abd pain). Eventually, became hypotensive & was transferred to the ICU for “initiation of vasopressors”. Phys exam: diffuse abd tenderness. Formal echo earlier that day: "Normal LV/RV in size and systolic function". ICU POCUS was done...
...to gain more information regarding the cause of the abd pain and the hemodynamic picture. Some of the clips are shown here:
ICU POCUS snippets: Much has been said about how useful lung POCUS is for procedural guidance. First of all, it accurately reveals large effusions when the radiology report characterizes them as “small”. This is from a recent case of a pt intubated w community-acquired pneumonia
and what proved to be bilateral parapneumonic effusions:
Secondly, while the dogma (which, btw, I don’t recommend completely ignoring!) in thoracentesis is to insert the needle at the “triangle of safety”, bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major, the horizontal line at the...
Today's #POCUS lecture by @mtabbut about the FAST exam in Hemodynamically Pediatric Blunt Abdominal Trauma. #MetroEUS
Aggregate sensitivity of FAST for all intra-abdominal injuries is low. Specificity is high. Remember though, the FAST was designed to look for FF, not all injuries. So if the injury is not associated with FF, the FAST will likely not see it.
So what can we do to increase the sensitivity of the FAST? Serial exams and adjunctive labs.
S/P MVC c Rt CP/SOB- 118/74, 112, 24, 96% RA. Supine pCXR. #FOAMed #FOAMcc #MedEd #MedTwitter #EMBound #Impocus #POCUS #FOAMus @msiuba @siddharth_dugar @ThinkingCC @khaycock2 @pdsalinas @msenussiMD @IM_Crit_ @KalagaraHari @iceman_ex @NephroP @EM_RESUS @jminardi21 @TomJelic
Management? @kyliebaker888 @medpedshosp @dan___kim @TaotePOCUS @Manoj_Wickram @ria_dancel @SmallsSono @drjgutt @medcramUS @POCUSaurusRex @PratsEM @HeyDrNik @MH_EMultrasound @MetroHealth_EM
Management if patient was tachypneic/hypotensive based on CXR?
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
Diagnosis? @TaotePOCUS @Manoj_Wickram @medpedshosp @msiuba @siddharth_dugar @vanessapho @tessanelson32 @Paul_Dreher_ @jilshim @aedrake65 @SpencerSeballos @thepocusatlas @POCUSaurusRex @SmallsSono @drjgutt @medcramUS @cianmcdermott @ThinkingCC @khaycock2 @IM_Crit_ @IMPOCUSFocus
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
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:
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?):
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:
Post holiday season, @ICUltrasonica, @wilkinsonjonny & I are back to take you through the most most critical clinical questions on #haemodynamics that ultrasound can answer
We’re now on to question 3 of FUSIC HD
’Is the aorta abnormal?’
#FUSIC #echofirst #POCUS #FOAMus
We’re now on to question 3 of FUSIC HD
’Is the aorta abnormal?’
#FUSIC #echofirst #POCUS #FOAMus
Aortic dissection is easily missed, carries a high mortality and should be on the differential of any patient with shock, abdo pain or chest pain. Contrary to popular belief the entire aorta can be imaged via transthoracic and abdominal ultrasound. Let’s start with some anatomy
Asc aorta:
Visualised from PLAX view with depth ⬇️ & probe tilted to focus on the root. Tilting superiorly, or moving up a rib space, may help. Examine the AV and look for a dissection flap. Measure the diameter 3-4cm from the AV. The root can also be seen from A5C & A3C views
Visualised from PLAX view with depth ⬇️ & probe tilted to focus on the root. Tilting superiorly, or moving up a rib space, may help. Examine the AV and look for a dissection flap. Measure the diameter 3-4cm from the AV. The root can also be seen from A5C & A3C views
Patient with epig pain and multiple ED visits with neg CT and non-specific labs - but persistent pain. What do you do? GI cocktail + famotidine and discharge? How about a little #POCUS first. #FOAMed #FOAMus #Ultrasound #MedTwitter @mtabbut @laurarbrownmd @RJonesSonoEM
And the transverse view. What do you think now? Poll below in thread. #Whatsthedx #EmergencyMedicine @DianeGramer @SLWerner_EM @ClaridgeJeffrey @vanessapho @ladha_prerna
What do you think?
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!
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!
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
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👍
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👍
Today's ultrasound lecture by @mtabbut about ultrasound guided nerve blocks. #metroEUS #FOAMed #FOAMus #MedTwitter #POCUS @SLWerner_EM @DianeGramer @RJonesSonoEM @MetroHealth_EM
Nerve blocks allow for the management of acute pain or painful procedures in the ED. Decreases need for opiates and sedations. Ultrasound guided vs blind decreases inadvertent vascular or nerve injection and allows targeted depot of anesthetic agent around the nerve.
Multiple studies demonstrate the efficacy of ultrasound guidance over landmark guidance.
