Discover and read the best of Twitter Threads about #pocus

Most recents (24)

Pt with advanced Cirrhosis

AKI, Oliguria + Encephalopathy

Initial treatment = Albumin + Lactulose enemas

🧂Na is now 158 (From Lactulose induced free water loss)

#POCUS ninja @tumleal noticed something was wrong! He got his probe and texted me

📱 #WhatsAppAKIConsult 1/5 ImageImage
#POCUS: Plethoric non collapsible IVC

Based on the clinical scenario, IVC, heart rate and Pulse Pressure...

What is the likely underlying pathophysiology? 2/5
@tumleal went ahead and confirmed his suspicion:

He 📲texted me this:

LVOT VTI = 38!

Some 🔢:

VTI of 38, assuming a LVOT diameter of 20 mm: Stroke Volume = 119 ml

119 ml x HR (93 bpm) = 11.1 L/min of CO!

This is High Output Heart Failure (Very common in Cirrhosis) 3/5 ImageImage
Read 5 tweets
Thread, 1/n - Male 75. Acute dyspnea since 1 hour, can't talk, wheezy. SPO2 75%. No previous record. "All that wheezes is not asthma". #POCUS leaves no doubt about pulmonary edema, Dx while patient is being attached to monitor.BP 180/110 mmHg.
2/n CPAP 10 mmHg, IV infusion of nitrate being prepared. Pectus excavatum, parasternal long axis impossible from usual 3/4 ICS. But Apical 4 chamber suggests mild LV systolic dysfunction
3/n As I was about to bolus nitrate 500 mcg - BP drops from 180/110 to 120/70 mmHg. Patient improving with CPAP. So I hold the bolus and try to get more cardiac views. Patient upright plus pectus excavatum, thus not the best quality, but aortic valve appears calcific.
Read 6 tweets
La Editorial del Año 👏

20 Recomendaciones MEJORES que las del Surviving Sepsis hechas por Expertos a Nivel Mundial 🌍…

Empecemos… (1/x)
1️⃣ El Ingreso a UCI debe ser en MINUTOS de que llegue el paciente grave a Urgencias

En algunos países No existen Urgenciólogos aún.
La idea es dar el tratamiento inmediato y posteriormente a UCI SIN RETRASO ✅

Nada de pedir/esperar estudios o pedir que se coloque un CVC ❌
2️⃣ Pacientes en tratamiento paliativo, al final de su vida, y con falla multiorgánica, podría considerarse no ingresar a UCI, consultar con ellos y su familia es importante 🧓🏼 y una buena comunicación.
Read 16 tweets
#POCUS y #SoMe4MV en #PedsICU
🔊en Ventilación Mecánica 🫁

Abro hilo, iniciamos, y abiertos los comentarios:
Esta información tuvimos el gusto de compartirla en el IV Curso Internacional de Medicina Intensiva Pediátrica dentro del XVI Congreso Internacional de Medicina Intensiva organizado por la @sopemi_org.
Gracias por la invitación. Ahora si, entremos en materia.
Los objetivos planteados en tres puntos:
Relacionar el Ultrasonido Pulmonar (LUS) y la Ventilación Mecánica (VM).
Conocer guías y monitoreo que nos ofrece el POCUS en VM y mencionar elementos evaluables por LUS.
Read 56 tweets
So I was wondering today, as an eternal student, a regional anaesthetist,and Past @RegionalAnaesUK president - what would make me want to attend #RAUKISURA22 on the 5-7th May 2002 in Edinburgh? So - Here Comes a mini thread!
@RegionalAnaesUK has been working hard to change the way we deliver education in #RegionalAnaesthesia
Check out some of highlights from #RAUK19 in Belfast organised by @LloydTurbitt @rosie_hogg @PeterMerjavy @davejohnston24 & Mike Jones
The Belfast meeting was the first time we used on stage symposia to bring an engaging feel to the event, & the first time we had such a North American & Canadian presence at our meeting + #POCUS with @KiJinnChin , @shaskinsMD , @SLKoppMD, @JanBoublikMDPhD
Read 15 tweets
1/ #tweetorial
⮞Optic disc edema vs. Papilledema
⮞Orbital anatomy
⮞Orbital #POCUS
2/ First what is 𝗽𝗮𝗽𝗶𝗹𝗹𝗲𝗱𝗲𝗺𝗮?

𝘐 𝘸𝘪𝘴𝘩 𝘐 𝘤𝘰𝘶𝘭𝘥 𝘨𝘦𝘵 𝘪𝘮𝘢𝘨𝘦𝘴 𝘭𝘪𝘬𝘦 𝘵𝘩𝘦𝘴𝘦...
3/ 𝗢𝗽𝘁𝗶𝗰 𝗱𝗶𝘀𝗰 𝗲𝗱𝗲𝗺𝗮 = optic nerve head edema + anterior bulging of physiologic cup

𝗣𝗮𝗽𝗶𝗹𝗹𝗲𝗱𝗲𝗺𝗮 is optic disc edema 𝙙𝙪𝙚 to 🡱intracranial pressure

**𝗡𝗼𝘁 𝗮𝗹𝗹 𝗼𝗽𝘁𝗶𝗰 𝗱𝗶𝘀𝗰 𝗲𝗱𝗲𝗺𝗮 𝗶𝘀 𝗽𝗮𝗽𝗶𝗹𝗹𝗲𝗱𝗲𝗺𝗮 []
Read 13 tweets

I think there is a misconception about hemodialysis (HD), definitely not a recipe. We have to individualize every patient; when we combine HD + plasma refilling rate (PRR) + #POCUS I can assure you, we are improving our game! All made in @NefrologiaINC
As we all know, 2/3 of total body water (TBW) is intracellular and 1/3 extracellular this last one subdivides in extravascular (75%, interstitial & lymph; connective tissue & bone; body cavities; adipose tissue), and intravascular (25%, plasma volume) DOI: 10.1681/ASN.2011080865
What about forces governing water distribution? Starling forces pops out into our head, but we should not forget charged proteins, which generate colloid osmotic pressure (Donnan effect) favoring untenable water entry.
Read 20 tweets
Tamponade tweetorial
68m with a h/o COPD and lymphoma, presented with SOB unrelieved with home albuterol. Had an O2 sat 88% with EMS which improved with CPAP. BP 87/50 and HR 160 which improved to BP 127/70 and HR 115 after 1 L of LR. Exam had increased WOB and clear lungs
CXR showed cardiomegally which prompted cardiac #POCUS. Any significant SOB patient should have a cardiac and lung #POCUS to quickly assess for emergent pathology
PSLA view showed a clear large pericardial effusion. Given the patient's clear lung exam (and normal lung #POCUS), this can certainly be the cause.
Read 13 tweets
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
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
Read 20 tweets
#Ecocardiografía y Cálculos Hemodinámicos

Este Sábado 16 de Octubre estuvo con nosotros la Dra. Eva Lemos para hablar de #POCUS, & #FoCUS específicamente.
¿Te lo perdiste?🚩

Estará en #YouTube y abrimos 🧵 con algunos de los puntos más interesantes y comentarios extras:
Las bases son #Fundamentales.

Nos dió un recordatorio simplificado del sustento físico que nunca sobra al hablar de POCUS (y siempre se hecha de falta si no se tienen las bases).
Características del US, donde ocuparás varias palabras de las cuales debes estar familiarizado.
Y no podemos olvidarnos de la #interacción del haz del US y los tejidos.

🔇No toda emisión regresará al transductor y debes saber el por qué.
Read 25 tweets
This is a 🧵 about physical examination, and what role it (still) plays in modern clinical practice. Decided to write this after seeing a post earlier this yr by @RichardLehman1 on this issue and some people replying that examination was much less relevant in the modern era
I'd like to share 3 case examples of why I don't believe that is true. POCUS is a valuable *adjunct* to the initial clinical assessment, which includes both history & exam (H&E). The H&E should direct which tests you want & what Q you're asking

1. MR case
2. AS case
3. HF case
Case 1
Pt referred to @UHS_valveclinic with new murmur. Completely asymptomatic, very fit & active. Phys exam revealed a prominent systolic murmur, no other abN findings.

TTE images were is PLAX

@echo_stepbystep @iamritu @purviparwani @rajdoc2005 @mswami001
Read 23 tweets
The JVP exam has been with us since 1930 when Sir Thomas Lewis first proposed this exceptionally clever technique. A #pocus thread. Image
He knew that in heart failure there in “congestion of the veins” and when they become engorged can be detected on the neck.
Here is a phenomenal example in a very thin patient with prominent veins.
Read 10 tweets
One of my favorite and most intriguing causes of severe venous congestion (#VExUS = 3)

A 🧵on High Output Heart Failure (HOHF) 1/18
First, the index case:

Clip above shows hyperdynamic flow from the vena cava

#echofirst 👇: Very dilated and plethoric IVC, LV OK, Dilated RV, D sign

Overall: Increased Right heart filling pressures

IVC = 3.4 cm
Portal Vein = > 100% pulsatility
TRVmax = 3.04 m/s

So we have:

Venous Congestion (IVC, Portal Vein)
High Cardiac Output (LVOT-VTI)
Pulmonary Hypertension (TRVmax)

Read 18 tweets
#POCUS con USPed Latinoamérica🌎

En #SabadosdePOCUS Roberth González Cardiólogo Pediatra de 🇵🇪 nos habló de #Ecocardiografía en el Paciente #Critico en #Pediatria.

¿Quieres saber un poco de qué trato?

Abrimos 🧵 👩‍⚕️👨‍⚕️
Comentarios iniciales #PedsICU:

No vemos internamente la interacción cardiopulmonar. El #POCUS ha cambiado eso.
Dicha interacción regularmente había sido estudiada por separado.
La integración ❤️-🫁Pulmón debe ser siempre en contexto.

Algo que le sirvió mucho al Dr. Roberth: la #Fisiología, su funcionamiento.

Ojo, este dato se ha mencionado mucho en nuestras sesiones. El #POCUS en verdad te ayuda a mejorar tus conocimientos básicos, cuando ves lo que tanto estudiaste.
Read 21 tweets
Fantastic to see this multi-author publication. The state of gender inclusion in the #POCUS community. A thread of highlights from the paper. 🧵1/7
In 1994, #JamesMateer trained the 1st American emergency #POCUS fellows: 3 women #BethThoma
#VerenaValley @mbphelan pioneered the field at @MedicalCollege. Despite the historic beginning, women remain underrepresented in #POCUS. 🧵 2/7
@ACEP_EUS has elected 6 women chairs out of 25. One of 10 physician members of @ACEPNow Clinical Ultrasound Accreditation Program is a woman. 🧵 3/7
Read 7 tweets
En nuestros #SabadosdePOCUS tuvimos a @ACRP901 con el tema:

"Los Secretos Ecográficos de la Vena Cava Inferior (#VCI/#IVC)"

¿Quieres enterarte de alguna puntos claves?

Abrimos hilo... 🧵 #POCUS
Un punto clave del Dr. @ACRP901: "Los niños no son adultos pequeños"
La VCI sigue siendo esquiva.
Es #Fundamental conocer la fisiología y anatomía al tocar este tema.
Y recuerda: los secretos se encontrarán en la #Fisiología más que en la ecografía per se.
La #VCI se encuentra inmersa en varios protocolos y en las modificaciones de cada uno de estos dependiendo el contexto del paciente (#FOCUS, #RUSH, #EFAST).

Se habían utilizado a la #VCI regularmente para medir el estado de volemia y una posible respuesta (o no) a fluidos.
Read 25 tweets
Ecocardiografía desde Ventana Subxifoidea🫀

En nuestros #SabadosdePOCUS tuvimos de invitado a @areinamo21 🇻🇪 radicando en 🇺🇲, Cardiólogo Pediatra con estudios en Cuidados Cardiovasculares.

¿Quieres saber algo de lo que aprendimos en #POCUS esta sesión?
Abrimos 🧵... #PedsICU Image
Importante conocer la ventana, dónde se realiza, cómo agarrar la sonda, en qué situaciones nos es bastante útil y saber sus #Pros y #Contras.

Queremos verte crecer juntos, recuérdalo. Image
No sólo en #PedsICU se realiza. También #Neonatologia se beneficia de su visualización.
La Ventana Subxifoidea se consideraba la "Ventana del Intensivista o Urgenciólogo".
Su 📜 papel principal: evaluación rápida hemodinámica. Image
Read 8 tweets

👴 w Advanced Cirrhosis, hemorrhagic portal hypertension and hx of a heart block (w pacemaker).

Came to the ED w diarrhea 2/2 severe C. Diff.

Now in shock...

Initial resus with Norepinephrine 0.3 ug/kg/min, Crystalloid and albumin. Cr 3.8

18 hrs later, no renal improvement + oliguria.

MABP 70, CRT 2 seconds. 🧠 confused, + asterixis. No ascites or edema

Workup: hemodynamic AKI (⬆️SG, ⬇️UNa, ⬆️BUN/Cr, bland sediment)

Team wants to continue fluids, albumin and antibiotics... Dr. Harris, do you concur?

Obviously you are here for the #POCUS so here we go:

IVC: Plethoric (No subX window 2/2 intestinal air)
LV, RV: Relatively preserved systolic fx
Pacemaker lead seen causing important Tricuspid Regurgitation!

Read 7 tweets
1/7 Let’s go over the evidence-based physical exam for lower extremity deep vein thrombosis (LE DVT). In the spirit of quantifying clinical concern, here is a question - besides inspection (and #POCUS), which tool will help you the most?

#MedTwitter #FOAMed #MedEd
2/7 The answer is a ruler! Let’s look at the LRs.

Quick review of LRs:
- The (+) and (-) indicate the LR if a finding is present or absent, respectively
- The more the LR deviates from 1, the more useful it is
3/7 For this particular set of exam findings, it may be more helpful to see how much the LRs change your post-test probability (assuming a pre-test probability of 50%). The presence of absence of asymmetric calf swelling seems to be the most helpful.

Graphic from McGee
Read 7 tweets
We’ve seen how to measure VTI and stroke volume with #ultrasound
Our next #FUSIC haemodynamic question brought to you by @icultrasonica, @wilkinsonjonny and I is:

Q2. Does SV respond to fluid, vasopressors or inotropes?

#echofirst #POCUS #haemodynamics #foamed
In Q1 we saw how to measure stroke volume (SV). Q2 helps us manage someone with an inappropriately low SV. Pressors, fluids and inotropes are all treatment options. If If used correctly, they will ↑SV. If not, they won’t, and they may even be harmful.
Measuring VTI before and after each of these interventions will therefore easily show you if they have worked. But can we predict which one is likely to work before we give drugs or a drop of fluid? 1st, let’s go back to some physiology.
Read 25 tweets
#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 🧵below:
#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 IVC👇
Read 9 tweets
What are the key clinical questions about haemodynamics that ultrasound can answer?

@icmteaching, @wilkinsonjonny and I are going to take you through the 10 most important…

starting with...

Q1. Is stroke volume abnormal?

#FUSIC #echofirst #POCUS #ultrasound #haemodynamics
Despite shock being such an important diagnosis, intensive care clinicians are rubbish at detecting a low or high cardiac output (CO) clinically.

Sensitivity of detecting cardiac index (CI) < 2 clinically in this study was 0!…
From an apical 5- or 3-chamber view we can use PW Doppler to assess the velocity time integral (VTI) in the LVOT to determine blood flow.

Essentially, LVOT VTI is the average distance travelled by ejected blood during one contraction...

It is also known as stroke distance.
Read 12 tweets
1/8 Let's review assessment of hypovolemia based on physical exam. (yes, I know #POCUS is SO valuable in making this assessment)

Which physical exam finding is most useful to detect hypovolemia in adults?

#MedTwitter #FOAMed #MedEd #MedStudentTwitter
2/8 According to a great review by Dr. McGee in JAMA Rational Clinical Exam "Is This Patient Hypovolemic" the answer is... sunken eyes!… Image
3/8 For a way to clinically interpret the LRs, let's turn our attention to Dr. McGee's book "Evidence-Based Physical Diagnosis." Although sunken eyes has the highest LR, notice how small the difference in increase in probability there is with each exam finding. Image
Read 8 tweets
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?
Read 9 tweets

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