Discover and read the best of Twitter Threads about #hrreloaded
Most recents (17)
Index thread linking together all the talks at #HRreloaded! In case you got lost in the tweet storm, you can scroll through this to find any talks you might have missed...
𧡠of π§΅'s...
𧡠of π§΅'s...
@ThinkingCC on when to intubate the COVID patient
@emcrit on how to avoid hemodynamic assassination during intubation
Avoiding airway catastrophe!
When things go sideways, don't be passive
How can we harness a team appropriately?
- @drlauraduggan at #HRreloaded
When things go sideways, don't be passive
How can we harness a team appropriately?
- @drlauraduggan at #HRreloaded
closed claims analysis: what patterns emerge?
10-12 teaching cases in the back are worth reading
- @drlauraduggan at #HRreloaded
10-12 teaching cases in the back are worth reading
- @drlauraduggan at #HRreloaded
30YO woman in plastic surgery office for breast augmentation. 40 minutes of attempts with laryngoscopy and bag-mask ventilation. cric performed after bradycardic and somehow pt did well. errors = lack of LMA, perseveration
- @drlauraduggan at #HRreloaded
- @drlauraduggan at #HRreloaded
folks figured out trans-cranial doppler using M-mode probes. amazing. this makes me feel really guilty for struggling with a 2D probe.
- @ottawaheartrob at #HRreloaded
- @ottawaheartrob at #HRreloaded
relevant anatomy - imaging parallel to the base of the brain, looking at the circle of willis
- @ottawaheartrob at #HRreloaded
- @ottawaheartrob at #HRreloaded
data from Italy:
- increased incidence of arrest during COVID surges (greatest in provinces with highest COVID rate)
- more unwitnessed arrests, higher field mortality, lower rate of bystander CPR
- @FTeranMD at #HRreloaded
- increased incidence of arrest during COVID surges (greatest in provinces with highest COVID rate)
- more unwitnessed arrests, higher field mortality, lower rate of bystander CPR
- @FTeranMD at #HRreloaded
data from Paris:
- higher rate of arrest during COVID pandemic
- more arrests at home, lower bystander CPR, longer delays to intervention, fewer people alive at hospitalization
- @FTeranMD at #HRreloaded
- higher rate of arrest during COVID pandemic
- more arrests at home, lower bystander CPR, longer delays to intervention, fewer people alive at hospitalization
- @FTeranMD at #HRreloaded
OMI vs. NOMI: The STEMI/NSTEMI is a failed pardigm!
- many NSTEMI have occlusion
- many STEMI don't have occlusion
- @PendellM at #HRreloaded
- many NSTEMI have occlusion
- many STEMI don't have occlusion
- @PendellM at #HRreloaded
- we've tried putting band-aids on STEMI.
- the list of STEMI-equivalents keeps growing!
- unfortunately there's no consistent approach to these (cath lab may refuse to activate)
- @PendellM at #HRreloaded
- the list of STEMI-equivalents keeps growing!
- unfortunately there's no consistent approach to these (cath lab may refuse to activate)
- @PendellM at #HRreloaded
- STEMI algorithm evolved from prior QWMI/NQWMI pardigm, based on RCTs involving thrombolysis
- STEMI is an improvement on ignoring EKG entirely, but it's deeply flawed
- OMI is the next pardigm
- @PendellM at #HRreloaded
- STEMI is an improvement on ignoring EKG entirely, but it's deeply flawed
- OMI is the next pardigm
- @PendellM at #HRreloaded
POCusing the RUQ!
Themes of the presentation (and life in general)
- certainty stifles science
- look at US with soft eyes
- @kyliebaker888 at #HRreloaded
Themes of the presentation (and life in general)
- certainty stifles science
- look at US with soft eyes
- @kyliebaker888 at #HRreloaded
diagnostic pardigm depends on pre-test probability!
starting out with accurate pre-test probility essential
- @kyliebaker888 at #HRreloaded
starting out with accurate pre-test probility essential
- @kyliebaker888 at #HRreloaded
one series of ED patients with RUQ pain: 1/3 of patients with cholecystitis. thus, most patients with RUQ pain will have some other pathology - don't anchor too soon!
- @kyliebaker888 at #HRreloaded
- @kyliebaker888 at #HRreloaded
Additional frontiers in venous congestion: What does it mean if there is pulsatile venous flow in the *femoral* vein?
This was origionally in patients with elevated CVP...
- @Ad12Andre at #HRreloaded
This was origionally in patients with elevated CVP...
- @Ad12Andre at #HRreloaded
additional studies showing that pulsatile venous flow correlates with elevated CVP.
- @Ad12Andre at #HRreloaded
- @Ad12Andre at #HRreloaded
VEXUS score to assess systemic congestion via ultrasonography. Systemic venous congestion is dangerous for multiple reasons, so early identification and management may be important.
- @WBeaubien at #HRreloaded
- @WBeaubien at #HRreloaded
interpretation of hepatic vein doppler waveform:
normal: systolic equal or greater than diastolic
mild: systolic smaller
severe: systolic reversal
- @WBeaubien at #HRreloaded
normal: systolic equal or greater than diastolic
mild: systolic smaller
severe: systolic reversal
- @WBeaubien at #HRreloaded
Improvement of Portal Vein Pulsatility with CRRT fluid removal.
Possible use to predict Intra-dialytic hypotension? @NephroP
Possible use to predict Intra-dialytic hypotension? @NephroP
Ping #VexusTeam @incmnszmx @SergioAlday11 and #VexusTeam at Hospital General de MΓ©xico @HGM_OD @galindozip @pepeska015
Secret Weapon - Inhaled Pulmonary Vasodilators!
When managing the sickest patients with RV failure or hypoxemia, these can come in clutch.
#HRreloaded
When managing the sickest patients with RV failure or hypoxemia, these can come in clutch.
#HRreloaded
Inhaled pulm vasodilators do roughly three things physiologically. First, they pull blood towards the best-ventilated alveoli. This improves ventilation/perfusion matching and oxygenation. (Yep it always comes back to VQ matching.)
#HRreloaded
#HRreloaded
#2) Some patients with ARDS develop a right --> left shunt. these patients can be hard to treat, because increasing airway pressures (e.g. recruitment) may *increase* pulmonary vascular resistance and worsen the shunt! pulmonary vasodilators can reduce shunting
#HRreloaded
#HRreloaded
Zentensivism doesn't mean not responding rapidly when necessary. but it may mean rapid de-escalation of therapy when possible. when the patient is improving, allow them to heal and get out of the way.
- @msiuba at #HRreloaded
- @msiuba at #HRreloaded
"they quote need a bronchoscopy" I'm dying π€£.
Zentensivist - do more with fewer interventions
- @msiuba at #HRreloaded
Zentensivist - do more with fewer interventions
- @msiuba at #HRreloaded
how to get the views
(1) parasternal short axis or a modified parasternal long axis view that looks at the RVOT
(2) can get good doppler angles from subcostal windows
- @khaycock2 at #HRreloaded
(1) parasternal short axis or a modified parasternal long axis view that looks at the RVOT
(2) can get good doppler angles from subcostal windows
- @khaycock2 at #HRreloaded
Pw gate right before the pulmonic valve
PVAT is acceleration time - this reduces with pulmonary HTN.
- @khaycock2 at #HRreloaded
PVAT is acceleration time - this reduces with pulmonary HTN.
- @khaycock2 at #HRreloaded
flipping the vent! CPAP & APRV
- usually we dichotomize vent into 1st forcing patient to obey our tidal volumes, only later on allowing patients to breathe on their own
- CPAP/APRV: patient breathes on their own from the start
- @EMNerd_at #HRreloaded
- usually we dichotomize vent into 1st forcing patient to obey our tidal volumes, only later on allowing patients to breathe on their own
- CPAP/APRV: patient breathes on their own from the start
- @EMNerd_at #HRreloaded
to breathe, we need 3 things:
1) neurological drive to breathe (often depends on sedation and analgesia)
2) working diaphragm
3) adequate compliance
- @EMNerd_at #HRreloaded
1) neurological drive to breathe (often depends on sedation and analgesia)
2) working diaphragm
3) adequate compliance
- @EMNerd_at #HRreloaded
most patients have problems with #3 - patients are operating with a compressed "baby lung" which isn't at their normal residual volume. CPAP may bring the patient back to their resting lung volume, allowing the patient to breathe on their own.
- @EMNerd_at #HRreloaded
- @EMNerd_at #HRreloaded
POCUS is the most accessible way to investigate the diaphragm in critical care (patients may not be excited about swallowing an esophageal balloon)
- @drmarcogarrone at #HRreloaded
- @drmarcogarrone at #HRreloaded
apposition zone - diaphragm thickens with contraction
diaphragmatic zone - downward translational motion
- @drmarcogarrone at #HRreloaded
diaphragmatic zone - downward translational motion
- @drmarcogarrone at #HRreloaded
ECMO has been around since the 1970s. this image shows a successful ECMO run! however, ecmo in the 1970s wasn't generally awesome.
- @iceman_ex at #HRreloaded
- @iceman_ex at #HRreloaded
- current ECMO: portable, may be started in the field.
- remainder of talk will focus on venovenous ECMO.
- @iceman_ex at #HRreloaded
- remainder of talk will focus on venovenous ECMO.
- @iceman_ex at #HRreloaded
does ECMO work?
- CESAR trial: transport to ECMO center improved survival. Controversial b/c many patients didn't actually get ECMO.
- EOLIA trial: stopped early, but bayesian re-analysis suggested may be positive after all ?!?
- @iceman_ex at #HRreloaded
- CESAR trial: transport to ECMO center improved survival. Controversial b/c many patients didn't actually get ECMO.
- EOLIA trial: stopped early, but bayesian re-analysis suggested may be positive after all ?!?
- @iceman_ex at #HRreloaded
how did we get to our current paradigm of ventilator support?
- historical approaches included hanging upside down and rolling patients over barrels (prone ventilation! what's old is new again?)
- @adamdavidthomas at #HRreloaded
- historical approaches included hanging upside down and rolling patients over barrels (prone ventilation! what's old is new again?)
- @adamdavidthomas at #HRreloaded
heterogeneity! variations in compliance and lung disease will drive differences in optimal ventilation strategy
- @adamdavidthomas at #HRreloaded
- @adamdavidthomas at #HRreloaded
as soon as bellows started being used to ventilate, it became evident that excessive volume could cause harm! (previously, mouth-to-mouth resuscitation naturally prevented barotrauma)
- @adamdavidthomas at #HRreloaded
- @adamdavidthomas at #HRreloaded
Weingart on hemodynamic assassination due to intubation
- preintubation hypotension = primary risk factor
- primary physiology = loss of catechols & transition from negative to positive pressure (reduces preload)
- @emcrit at #HRreloaded
- preintubation hypotension = primary risk factor
- primary physiology = loss of catechols & transition from negative to positive pressure (reduces preload)
- @emcrit at #HRreloaded
Protective pathway for intubation
- separate out dissociation vs. paralysis
- 1st titrate ketamine to unawareness (ensures adequate dose but not too much)
- 2nd paralyze with high dose (2 mg/kg roc!) - ensures rapid onset
- @emcrit at #HRreloaded
- separate out dissociation vs. paralysis
- 1st titrate ketamine to unawareness (ensures adequate dose but not too much)
- 2nd paralyze with high dose (2 mg/kg roc!) - ensures rapid onset
- @emcrit at #HRreloaded
Hemodynamically *neutral* path avoids rapid transition from negative --> positive pressure
- Purest form = awake intubation
- Addition of ketamine may facilitate in agitated pt
- Bronchoscopic intubation may involve least stimulation
- @emcrit at #HRreloaded
- Purest form = awake intubation
- Addition of ketamine may facilitate in agitated pt
- Bronchoscopic intubation may involve least stimulation
- @emcrit at #HRreloaded
