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Randomised clinical trials in cardiogenic shock in the PCI era 
Treatment considerations for patients with AMI-cardiogenic shock
Enrolment data for major randomised cardiogenic shock trials (EuroIntervention 2021; 17: 451-65)
For #MedStudentTwitter , here r some urological terms explained:
👉Hesitancy- Delay in starting urination
👉Intermittency-A complaint received from the patient that the urine flow stops & starts during the urination episode.
👉Pyuria- Pus in urine. A thread 🧵(1/n)
👉Hesitancy- Delay in starting urination
👉Intermittency-A complaint received from the patient that the urine flow stops & starts during the urination episode.
👉Pyuria- Pus in urine. A thread 🧵(1/n)
👉Pyelonephritis- Infection of the kidney
👉Renal Calculus-Kidney Stone
👉Azoospermia-Absence of sperm in semen.
👉Cryptorchidism: A birth defect in which the testes fail to descend from the abdomen into the scrotum
👉Cystocoele- The urinary bladder has herniated into the vagina
👉Renal Calculus-Kidney Stone
👉Azoospermia-Absence of sperm in semen.
👉Cryptorchidism: A birth defect in which the testes fail to descend from the abdomen into the scrotum
👉Cystocoele- The urinary bladder has herniated into the vagina
👉Cystogram- A special Xray of the bladder,after filling it with contrast( thro a catheter)
👉ESWL- A treatment procedure where shock waves are given to painlessly break kidney stones
👉Enuresis: Involuntary urination
👉Urinary Incontinence: Loss of bladder control(3/n)
👉ESWL- A treatment procedure where shock waves are given to painlessly break kidney stones
👉Enuresis: Involuntary urination
👉Urinary Incontinence: Loss of bladder control(3/n)
Some unpopular opinions for new medicine interns that I wish someone told me one year ago:
#Interns #MedStudentTwitter #Medicine #MedTwitter
#Interns #MedStudentTwitter #Medicine #MedTwitter
1. When you get your schedule, you'll hear that you’re starting on the worst block/service/etc.
Ignore that. Like med school, intern experiences depend on unpredictable factors like who you work with, availability of resources, proximity to free food, etc. It's super variable.
Ignore that. Like med school, intern experiences depend on unpredictable factors like who you work with, availability of resources, proximity to free food, etc. It's super variable.
2. People will tell you to separate work and home.
Instead, do whatever you want. If you pre-chart better at home or want to note-prep before going in, if it helps you know what's ahead, do it. Check on your patients on your day off if you want. It's okay to worry about them.
Instead, do whatever you want. If you pre-chart better at home or want to note-prep before going in, if it helps you know what's ahead, do it. Check on your patients on your day off if you want. It's okay to worry about them.
ICU stories (common): Middle-aged pt w hx of COPD was brought to the ED by EMS after SOB x 2 days. No fever or chest pain. Very quickly after ED arrival, he was intubated. CXR showed hyperinflated, “COPD” lungs. Here depicted in two images:
Post-intubation ABGs showed:
BP dropped post-intubation to 55/40; propofol was started & then discontinued due to hypotension. iv fluids (2L Lactate Ringer's) were started & patient was brought to the ICU w SBP in upper 80s. Re-institution of propofol led again to hypotension. What would be the next step?
PICC line 🧵 #medicine
1/
A central device (i.e in the SVC) placed via a peripheral venous access
.
#irad #vascular #MedTwitter #FOAMed #hematology #Tweetorials @nihardesai7 @MedTweetorials #Cardiology #MedEd #oncology #internalmedicine @BrownJHM #MedStudentTwitter #cardiotwitter
1/
A central device (i.e in the SVC) placed via a peripheral venous access
.
#irad #vascular #MedTwitter #FOAMed #hematology #Tweetorials @nihardesai7 @MedTweetorials #Cardiology #MedEd #oncology #internalmedicine @BrownJHM #MedStudentTwitter #cardiotwitter
2/
Classically placed in the arm
May be placed in the leg (eg in #pediatrics /neonates – which may then terminate in the infrarenal IVC/iliacs)
.
#criticalcare #cardiovascular
Classically placed in the arm
May be placed in the leg (eg in #pediatrics /neonates – which may then terminate in the infrarenal IVC/iliacs)
.
#criticalcare #cardiovascular
3/
Advantages:
- Lower infection rate then central lines
- Used in the outpatient setting
- Can be used for several weeks to months
- Duration of PICC lines may be from 4 weeks to 6 months
(although they have been known to be functional for more than 300 days)
Advantages:
- Lower infection rate then central lines
- Used in the outpatient setting
- Can be used for several weeks to months
- Duration of PICC lines may be from 4 weeks to 6 months
(although they have been known to be functional for more than 300 days)
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:
INTRAVENOUS THROMBOLYSIS (fibrinolytic therapy) can be successfull if given
A. Within 30minutes to 12 hrs in STEMI
B. Within 3-4.5 hrs in Acute ischemic stroke
C. Within 14 days in Pulmonary embolism
Choose the ✅️correct statement/s among the above.
#Medtwitter #MedEd
A. Within 30minutes to 12 hrs in STEMI
B. Within 3-4.5 hrs in Acute ischemic stroke
C. Within 14 days in Pulmonary embolism
Choose the ✅️correct statement/s among the above.
#Medtwitter #MedEd
✅️TRUE statement/s among the above three
Fibrinolytic agents are plasminogen activators(PA) that act by converting plasminogen to plasmin. Plasmin then degrades the fibrin matrix of thrombi and produces soluble fibrin degradation products resulting in clot lysis.
I was checking again today about DKA/HHS in a very modern & easy to read textbook and I saw this about the Na correction:
The Katz correction factor is 1.6 mEq/L for every 100 mg/dL that the serum Glu exceeds 100 mg/dL & the Hillier correction factor is 2.4 mEq/L
amjmed.com/article/S0002-…
amjmed.com/article/S0002-…
It seems that the textbook 👆 uses a sodium correction factor of < 1.0 mEq/L for every 100 mg/dL of Glu above 100 or applies the correction starting from a higher Glu level (probably 200 mg/dL?)
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:
27 yrs old patient, detected to be pregnant when she missed her periods one day back. She has Graves disease on Rx for past 3 years, presently on Carbimazole 5mg daily and not on propranolol. She was euthyroid with Rx for past 1 year. Best strategy ?
Present reports 👇
Present reports 👇
A. Stop carbimazole and monitor by weekly/fortnightly TSH, FT4 levels and follow up.
B. Switch to PTU 50mg bd and do FT4, TSH after 2 weeks and review
C. Switch to PTU 50 mg bd + LT4 50mcg OD. TSH, FT4- 4wkly
D. PTU 50mg BD and Propranolol XL 20mg , Monthly TSH,FT4-followup
B. Switch to PTU 50mg bd and do FT4, TSH after 2 weeks and review
C. Switch to PTU 50 mg bd + LT4 50mcg OD. TSH, FT4- 4wkly
D. PTU 50mg BD and Propranolol XL 20mg , Monthly TSH,FT4-followup
1/”Tell me where it hurts.” How back pain radiates can tell you where the lesion is—if you know where to look!
A #tweetorial about how to remember lumbar radicular pain distributions.
#medstudenttwitter #medtwitter #radres #FOAMed #FOAMrad #neurorad #tweetorial #Meded
A #tweetorial about how to remember lumbar radicular pain distributions.
#medstudenttwitter #medtwitter #radres #FOAMed #FOAMrad #neurorad #tweetorial #Meded
2/Let’s start with L1. L1 radiates to the groin. I remember that b/c the number 1 is, well, um…phallic. So the phallic number 1 radiates to the groin.
3/Let’s skip to L3 for a second. I remember L3 is to the knee—easy, it rhymes!
What is meant my Pulsus Paradoxus ?
A one-stop pathophysiology thread you’d ever need 🧵
#MedTwitter #MedStudentTwitter #MedEd #FOAMed #CardioEd #USMLE #ICU #EMTwitter
A one-stop pathophysiology thread you’d ever need 🧵
#MedTwitter #MedStudentTwitter #MedEd #FOAMed #CardioEd #USMLE #ICU #EMTwitter
To understand Pulsus Paradoxus in detail,
It is essential to realise for a fact that, 1. Pleural pressure, 2. Abdominal pressure, 3. Heart chamber pressures & 4. Lung pressures, are all interconnected, interact & react among each other.
It is essential to realise for a fact that, 1. Pleural pressure, 2. Abdominal pressure, 3. Heart chamber pressures & 4. Lung pressures, are all interconnected, interact & react among each other.
As we inspire —> the diaphragm moves down, creating a more negative intra-pleural pressure & a more positive abdominal pressure —> this adds up to ⬆️ venous return to right atrium —> excess blood enters RV & ⬆️ right ventricular end diastolic pressure (RVED)
ICU stories: Pt w "severe COPD" (ex-smoker; FEV1 30%) / chronic hypoxic-hypercapnic resp failure on 2-4 l/m O2 @ home / diastolic HF / HTN / HLD was brought to the ED due to "altered mental status" & "shortness of breath". S/he left the hospital 3-4 months ago after an episode
of "COPD exacerbation" (the 4th during the last 12 months). In the ED: sat in low 80s & after a brief non-rebreather mask trial, pt was placed on NIV. ABGs: PCO2>100 (above detection limit), pH 7.14, HCO3 undetectable. Pt suffered 2 grand mal seizures, & after receiving
lorazepam & 2l NS, s/he was intubated (roc+keta) & rushed to the ICU. Per ED: ECG w sinus tach & CXR "COPD lungs" & R basilar infiltrate. Labs: WBC 14K, creat 2.0 (baseline 1.4). You examine the pt quickly: sedated-?paralyzed/decr BS & wheezing bil/trace ext edema/skin not cold
ICU stories (a brief one): A 40+ yo pt w hx of bipolar disorder/asthma/GERD/HTN was brought to the ED by EMS after his wife found him lethargic ("altered mental status"). Apparently, he had spent the previous 2 days isolated in his forest cabin. Upon ED arrival, he was obtunded
& was given Narcan with no improvement. Vitals: 140/90, hr 80, rr 22, afebrile, sat 97% on room air. He could respond to simple questions. CT brain was negative. Lab work/up showed Hct of 59%, wbc 11k, PLT 400k and a chemistry panel showed:
A urine drug screen was sent 👇 while patient admitted that he had probably taken more Xanax (alprazolam) pills than he should. However, he denied that he wanted to hurt himself.
ICU Reminders:
RV-predominant cardiogenic shock
RV failure criteria:
RV-predominant cardiogenic shock
RV failure criteria:
RV pressure-volume loops:
Etiologies of RV failure:
ICU "news":
Have you heard about the Doraya catheter? It is percutaneously deployed in the IVC below the level of the renal veins & works as a temporary iv flow regulator -> partially obstructing the venous flow -> ⬇️ cardiac preload & venous congestion
Have you heard about the Doraya catheter? It is percutaneously deployed in the IVC below the level of the renal veins & works as a temporary iv flow regulator -> partially obstructing the venous flow -> ⬇️ cardiac preload & venous congestion
In a very small preliminary study, the catheter was placed in 9 patients (LVEF 24±12%) for a mean duration of 8.5 hours. The catheter deployment led to significant pressure ⬇️ above the device 12.4±4.7 mmHg, when compared to unchanged pressure below the catheter 18.5±6.2 mmHg
Diuresis was 77.1±25 ml/h at baseline, and 200.8±93 ml/h during device deployment with average peak urine output of 294 ± 139 ml/h... Spot urine Na increased from 35 to 101 mmol/l
Reference:
jacc.org/doi/10.1016/j.…
Reference:
jacc.org/doi/10.1016/j.…
17 year girl with history of recurrent brief fainting episodes (> 8) preceded by palpitations & "anxiety". Normal vitals + physical exam on arrival at the ED.
Dismissed as panic attacks by multiple doctors, her first ever ECG.
Would you diagnose the same?
#MedTwitter Consent ✅
Dismissed as panic attacks by multiple doctors, her first ever ECG.
Would you diagnose the same?
#MedTwitter Consent ✅
Her ECG shows short PR intervals with slurred upstroke on the QRS complexes: Delta waves - signifying the presence of an accessory pathway which may lead to aberrant conduction & electrical "short circuits"
This is NOT a panic attack.
This is Wolff-Parkinson-White syndrome (WPW).
This is NOT a panic attack.
This is Wolff-Parkinson-White syndrome (WPW).
Pre-conceived anchoring bias and subsequent dismissal in clinical practice of medicine is not just #gaslighting, but also causes harm.
⛽🔥
#FOAMed #meded #CardioTwitter #EPeeps #MedStudentTwitter @EM_RESUS
⛽🔥
#FOAMed #meded #CardioTwitter #EPeeps #MedStudentTwitter @EM_RESUS
ICU Pharmacy pearls:
If u have not heard the news, there is a national shortage of IV hydrocortisone (HC) ...
ashp.org/drug-shortages…
So, if u are like me & use often HC in septic shock, u need to be aware of other options. If HC (Solu-Cortef®) is not available, consider use of
If u have not heard the news, there is a national shortage of IV hydrocortisone (HC) ...
ashp.org/drug-shortages…
So, if u are like me & use often HC in septic shock, u need to be aware of other options. If HC (Solu-Cortef®) is not available, consider use of
an alternative parenteral corticosteroid: methylprednisolone (MP) (Solu-Medrol®) or dexamethasone (D)
The "problem" w these two drugs is that they have minimal mineralocorticoid activity, so u may need to supplement them w fludrocortisone (FC)
The "problem" w these two drugs is that they have minimal mineralocorticoid activity, so u may need to supplement them w fludrocortisone (FC)
This should not be a totally unknown practice for intensivists, since the "prototype" of positive steroid trials in septic shock, the Annane trial published 20 years ago in JAMA (jamanetwork.com/journals/jama/…) implemented a 7 day course w iv hydrocortisone AND enteral fludrocortisone
How my half day work ✂️ on a Saturday is progressing…😄
1. Young lady with 🫀 disease referred by ENT doc with epistaxis 👃
1. Young lady with 🫀 disease referred by ENT doc with epistaxis 👃
Pounding heart 💓 with loud P2 & PSM at the lower left sternal area
I got the mother and she said since 6 months she is blue 🔵
Centralcyanosis➕Clubbing➕VSD➕PulmHTN
There was Hx of recurrent LRTIs in childhood.
I got the mother and she said since 6 months she is blue 🔵
Centralcyanosis➕Clubbing➕VSD➕PulmHTN
There was Hx of recurrent LRTIs in childhood.
I sent her 🏠 to get old records 🔖 and our suspicion of cyanotic CHD with incd 🫁 blood flow due to TOGV was right 🫵🏽
🧵1/12: Writing your first case report can be a rewarding experience as it allows you to contribute to medical literature and showcase your clinical expertise. Here's a step-by-step guide to get you started! #CaseReport #MedEd #MedTwitter
🧵2/12: Start by selecting an interesting or unique case that adds value to the presentation, diagnosis, or treatment of a condition. The case should provide new insights or challenge existing knowledge. #MedicalWriting #CaseSelection
🧵3/12: Look at existing literature for similar cases. If there are less than 20 cases reported on PubMed, it's a good indication that your case might be worth sharing. A thorough literature review is essential for a successful case report. #PubMed #LiteratureReview
An 85-YO in rural Mississippi: months of tender, erythematous plaques & edema on bilateral hands extending to the elbows & on feet extending below the knees with significant pain
🔬skin granulomatous inflammation & numerous AFB
Mycobacterial🧫:➖
1/19
#IDtwitter #dermatology
🔬skin granulomatous inflammation & numerous AFB
Mycobacterial🧫:➖
1/19
#IDtwitter #dermatology
A repeat skin extensive granulomatous inflammation (A), with Ziehl-Neelsen stain clusters of acid-fast bacilli throughout the dermis (B).
Kinyoun stain >9 AFB/high-power field (C & D).
2/19
DOI: doi.org/10.1128/jcm.00…
#dermpath #microbiology
Kinyoun stain >9 AFB/high-power field (C & D).
2/19
DOI: doi.org/10.1128/jcm.00…
#dermpath #microbiology
Molecular identification: 100% identity to multiple Mycobacterium leprae
BORDERLINE LEPROMATOUS LEPROSY WITH REVERSAL REACTION
3/19
#MedTwitter #MolBiol
BORDERLINE LEPROMATOUS LEPROSY WITH REVERSAL REACTION
3/19
#MedTwitter #MolBiol
Sotalol is a _____ antiarrhythmic agent
Video from Classify Rx 📱 onelink.to/classifyp
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:
