Discover and read the best of Twitter Threads about #pocus

Most recents (24)

Brief Tweetorial on Hepatic Vein Doppler in patients with Tricuspid Regurgitation. Two days ago I asked this question, most answered "B" which is what you would usually expect on severe TR (1/13)
Normal HV doppler has 3 (or 4) waves. 1) S wave: during systole, corresponds to x descent of RAP; 2) V wave: late systole (not always seen) 3) D wave: during diastole, (y descent of RAP) 4) A wave: during atrial contraction. S and D are antegrade. A and V are retrograde (2/13)
Large TR causes a large V wave on RAP and thus the Hepatic Vein shows reversal of the systolic wave. **Antegrade flow (from liver to heart) is shown below the baseline while retrograde flow (heart to liver) is show above the baseline. Example from some of my patients: (3/13)
Read 14 tweets
Welcome back! Time for #tweetorial part 2 of #periopmedicine meets #meded
This time? #GME!
I’m going to continue to look at this through the lens of my experience practicing perioperative medicine as an #IMproud internist

Let’s start with an “origin story”.

Do you know what my first exposure to the concept and question of “is this patient of an acceptable risk to proceed to the OR?” Was?

Want to take a guess?

It was on a hepatology elective! We were consulted to inform #periop risk discussions for a young patient with cirrhosis scheduled for an open abdominal surgery (fyi, this can be high risk)
It was a lightbulb moment for me as an IM resident!
Periop wasn’t just cardiac…
Read 24 tweets
This was a *CRAZY* busy week. I must have done 900 thoracenteses this week, so I had some questions about pleural effusions and their effect on dyspnea based on things I observed. Here are my take aways. #MedTwitter #MedEd #PulmCrit #FellowLife
1/ I felt like a hero - swooped in, did a thoracentesis, drained 1.5L... and her breathing didn't get better. I was like... 😕wtf. It turns out size of pleural effusion correlates poorly with dyspnea. This holds true for reduction in symptoms after thoracentesis.
2/ Did another thora, and his SpO2 was WORSE after. 😖I'm like... WHAT'S WRONG WITH ME? Things can actually worsen immediately after thoracentesis (even without mucking it up) for a few hours. Also, gas exchange issues DON'T correlate with the symptom of dyspnea!
Read 8 tweets
Did my fellows' curriculum lecture today, "Images in #Nephrology"
Thought of sharing the slides as a tweetorial. Goal is to present some 'classic' images that aid in kidney-related diagnoses. Not exhaustive; plan to make 2nd part as well.
#MedEd #FOAMed Not much POCUS involved!
1st question. Classic image but rarely encountered. Note the super high blood urea nitrogen and serum creatinine.
Here is the answer.....
Read 61 tweets
A lines, B lines, Consolidation… the ABCs of Lung Ultrasound

But what do they really mean?

Here we attempt a #tweetorial presenting a way of thinking about common patterns seen on lung ultrasound.

See table here for a summary, and thread below for details


We will start with a hypothetical case for illustration
65 y/o f w HFpEF, COPD admitted 4 days ago with acute pancreatitis (now resolved). You are prepping her for discharge but she is now short of breath/hypoxic requiring 4 L O2.

Reportedly coughed a lot after dinner yesterday. Has not gotten any inhalers or antiHTN meds this hosp stay.
Net positive 4L. HR 88 SpO2 90% 4L BP 165/90 RR 22 T 99.8. WBC 22 (from 12 a day ago).
JVP not seen RRR, +S1/S2, 2/6 SEM
Bibasilar crackles, No LE edema. BNP 150.

Read 19 tweets
Thread - (1/n) #POCUS findings in Left Main coronary occlusion.. this is not a STEMI - its WORSE ! M/50, 12 h intermittent chest pain. 2 hours of constant chest pain. Normal BP, no rales... but.. ECG horrible.
Thread - (2/n) #POCUS findings in Left Main coronary occlusion
Thread - (3/n) #POCUS findings in Left Main coronary occlusion: Cardiology fellow seeing patients .. they (and I) can't appreciate any rales.. but this is how lungs appear all over anteriorly
Read 6 tweets
#POCUS guided above elbow radial nerve block thread (1/n) Identification or radial nerve
#POCUS guided radial nerve block thread (2/n): Actual block administration
#POCUS guided radial nerve block thread (3/n): This patient's abscess was eminently suitable for this block: M/50, diabetic, throbbing pain, temp 39.5
Read 5 tweets
With the help of @PICJournalWatch @harrykchris we though we could put together a collaborative thread with useful #PedsICU resources like apps, websites, blogs and accounts. This thread is open so please don’t hesitate to add yours. Here are mine 👇🏻
- I-Perfuse: great tool for anything cardiovascular including #ECMO cannula sizes, equations, a calculator... very useful for #PedsCICU
- Heartpedia: awesome 3D models of heart anatomy. Also great for teaching at the #PedsCICU. And it was created by the great @pccm_doc
Apps continued:
- The Sanford Guide: it costs 25€/year. I’d pay 250€ since I use it everyday in the #PedsICU. Basically everything you need to now about antibiotics and bugs #PedsID.
Read 14 tweets
A/Prof George Condous encouraging a consistent approach with regard to nomenclature for 5 types of ovarian masses. As #POCUS practitioners we can improve or descriptions of these findings #WFUMB19
Papillations > 3mm perpendicular to the long axis of the base of the projection
Read 13 tweets
1/ OK - so the issue of competence and short courses appears to becoming my hobby horse! Another article released that confirms what we all know – doctors need time, motivation and good mentoring to attain competence in ultrasound. #POCUS
2/ Unsurprisingly 170/182 doctors responding in this study felt that they did not attain competence after 30 scans, 6 months post short course. Well thank goodness! I am relieved at the outcome but have many concerns.
3/Why is the title of this article suggestive that the cause of trainee competence somehow lies with the impact of an isolated short course? Why is it not more suggestive of the systemic requirements (cultural, academic. Economic etc…) to achieve competence?
Read 12 tweets
#POCUS #VenousEXcessUScore guided diuresis in ❤️renal sx. Pt w T2DM and CKDG4A3 with HFpEF. After multi-agent diuresis (targeted to normalize venous flow patterns) pt lost 14 kg and returned to basal kidney function. ¿Should we pursue "decongestion" goals in these pts? (1/13)
It's interesting that the recent statement from @American_Heart spends a great deal discussing Bioelectrical impedance Vector Analysis (BIVA) as an aid to guide discharge and diuresis goals (2/13)
There is some evidence that "Hidration Status" (by BIVA) at discharge predicts CV events better than BNP. However for some reason this study used admission BNP while it is most likely that discharge BNP is the one that matters (3/13)
Read 14 tweets
I listen to ~90 #Podcasts on a (semi) regular basis. Let me give you a rundown of ALL of them and why you should listen to some amazing #FOAMed, especially for all the new #EmergencyMedicine interns. #FOAMed #MedEd #medtwitter
First of all, you need a good podcast app. I absolutely love Downcast. Great app, gives you more control over playback, downloading, and allows you to categorize your podcasts into playlists (picture 2). This is where you get to customize your #FOAMed experience! #medtwitter
In no particular order,

- Anesthesia and Critical Care Reviews and Commentary (ACCRAC). Great insight into Crit Care from an anesthesia perspective. Coming from EM, this is great to listen to- much different from my day-to-day! #FOAMed #FOAMcc #CriticalCare
Read 88 tweets
#Tweetorial: Diagnosis of Malignant Pleural Effusion (#MPE) to accompany publication in @AnnalsATS:

⚓️#MPE: Pl. Effusions (#pleff) w/ neoplastic cells/tissue
⚓️Paramalignant eff: related to malignancy but not due to it eg: endobronchial obstruction or PE
Answer me this dear folks!
Why is it important to diagnose #MPE?

While you ponder, LUNG and BREAST are commonest primaries metastatic to the pleural space! PMID: 24360987
#MPE = poor prognosis, change management & may help locate primary!

Ferrer (PMID: 15764788): >=4 of these strongly suggest #MPE:
a) Dyspnea, chest pain, constitutional sympt
b) Symptoms >1 mo
c) No fever
d) Blood-tinged #pleff
e) CT suggestive (mass, atelectasis, adenopathy)
Read 18 tweets
IVC image acquisition #IMPOCUS #MedTweetorial.

These 2 IVC M-mode images were obtained from the same patient 10 seconds apart. How could they be so different?

60 m with hx of COPD, HFpEF, admitted w LLL PNA s/p abx and 1 L LR. HR 118 BP 110/70. IVC US was performed as a piece of info in determining whether to administer more IVF.

Measurement 1: 2.35-->0.92 (65% collapse)
Measurement 2: 2.22-->2.09 (5% collapse)

Why so different?

First of all, how do you look at the IVC?
A common method is subxyphoid long axis, B mode or M mode. See below
-photo from…
-excerpt from WikiM (…) for a nice description
-an annotated sample B mode image and M mode image

Read 28 tweets
#POCUS diagnosis of epididymitis (thread) n/1 - scanning at root of scrotum - sweeping from spermatic cord downwards to find epididymis - which is enlarged and has complex appearance.
n/2 inflamed epididymis - complex appearance, increased vascular flow
n/3 sweeping from epididymis (inflamed) to testis (which is normal)
Read 5 tweets
Traumatismo Craneoencefálico

Abro hilo, iniciamos, y abierto a tus comentarios

Iniciamos con Abordaje Prehospitalario e Inicial en el TCE (parte 1/2)

Ayúdame a difundir @eduk_salud @aline_zarate @dralexgiles @Afedokmate1 @GMonraz @GabiOrtz
Todos los órganos son importantes, pero uno de ellos está procesando esta información, abrió la 👩‍💻 , desbloqueó el 📱, se despidió de sus seres queridos en la mañana.
Si nos falla un órgano, podemos suplantarlo, y seguimos siendo nosotros mismos. Pero si falla el 🧠, eso cambia.
El TCE lo definimos como una lesión estructural cerebral resultado de una fuerza física externa transmitida a la cabeza que interrumpe la arquitectura y función normal del cerebro.
Este hilo, nos vamos a enfocar al TCE severo.
Read 38 tweets
#POCUS image (transverse probe orientation in suprapubic region) in a 20 year old lady (language barrier++) with history of lower abdominal pain and recurrent vomiting since 20 days. Pregnancy test negative. Exam - fullness in lower abdomen, tenderness, no peritonism.
Saggital suprapubic #POCUS image
All sorts of differentials pass through - including obstetric fistula.... but patient has just passed urine - so repeat scan after full bladder.. with CT images 5 h later.
Read 5 tweets
#POCUS appearance of pneumoperitoneum (thread) - appreciate how normally abdominal wall, peritoneal line and intraperitoneal structures can be appreciated
Pneumoperitoneum causes peritoneal line to be enhanced, and gas scatter beneath means intraperitoneal structures can't be seen. Instead, reverberation artefacts from peritoneal line - similar to pleural A-lines - can be seen.
#POCUS at borderzone of pneumoperitoneum can show "peritoneal point" (cf. lung point in pneumothorax)
Read 7 tweets
Yes, it's terrible that interns only spend 12% of their time with patients. However, this isn't an entirely new phenomenon, and computers aren't totally to blame. How little time interns spend with patients has been observed since at least 1959 1/…
in 1961, Payson et al published in @NEJM a time study of 2 interns, conducted in 1959.

Their conclusion: "The finding that concerned us most was the small amount of time spent with patients." 2/…
Intern B in the @nejm study didn't have a computer, but he also wasn't spending too much time directly with patients. 3/
Read 9 tweets
A new #echofirst #POCUS #medthread CASE!

55 yo woman with hx of metastatic lung CA, known malignant pleural/pericardial effusions presents as a transfer in shock with associated encephalopathy. HR 120s-130s (sinus), cool extremities, MAP 65 on 8-10 mcg/min norepi. O2 4L NC.
What are you going to do based on the above image?
The LV cavity appeared small/underfilled to you in the first image, not sure why, but you elect to bolus IV fluids while you complete your exam. You move to the A4C view and notice this:
Read 9 tweets
Assessment of Fluid Overload and Hypervolemia (1/8)

Clinical assessment and signs for #FO are aspecific and unreliable:
-pitting edema
-positive fluid balance
-hepatojugular reflux

Preparing for #smacc #ISICEM19 #IFAD2019 #WCACS2019
Assessment of Fluid Overload and Hypervolemia (2/8)

Biochemical Assessment for #FO is aspecific and unreliable:
-low COP
-low osmolality

Preparing for #smacc #ISICEM19 #IFAD2019 #WCACS2019
Assessment of Fluid Overload (FO) and Hypervolemia (3/8)

Radiological and #POCUS imaging and signs for #FO are aspecific and unreliable:
- Absence of #IVCC
- Kerley-B lines
- Lung ultrasound B-lines
- Pleural effusions

Preparing for #smacc #ISICEM19 #IFAD2019 #WCACS2019
Read 7 tweets
This is the bedside Echo of a critically ill young lady who presented to the ER in shock

Those bright, whip-like structures emanating off the tricuspid valve are infective vegetations. They look similar to blood clots-in-transit except that instead of free floating you can see that they are tethered down.

The Right Ventricle (RV) should normally be about half the size of the Left Ventricle (LV). But here the RV is more than double the size of this underfilled LV!

Why would a patient with endocarditis also have right heart strain?

Read 11 tweets
#POCUS in cardiac arrest - keep probe on prior to pulse check pause - avoid delays searching for window - to minimize duration - and record a 3 sec loop which can be analyzed later. (thread)
(continued) this is what image looked like at pulse check - Dilated RV with septum bowing towards LV - should we give fibrinolytic for possible pulmonary embolism?
#POCUS is just a data point - in overall clinical context - additional data - this was a out of hospital VF arrest. With PE - we would expect a PEA arrest. Moreover, no risk factor for PE - and in fact, patient is on long term warfarin for AF - a "negative risk factor" for VTE?
Read 9 tweets
#POCUS in a gentleman with LUQ tenderness after blunt abdominal trauma 1 week ago. What is seen caudal to the spleen?
Perisplenic hematoma was suspected - and CT was performed
This is a normal anatomical variant of elongated left liver lobe - so called "Beaver tail liver"
Read 5 tweets

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