Discover and read the best of Twitter Threads about #vexus

Most recents (24)

#POCUS enthusiasts, is this IVC normal, abnormal? (asking about possibilities, not definitive conclusions)
#FOAMcc #MedEd #Nephpearls
(Transverse view in thread)
IVC transverse #POCUS
#POCUS answer:
I deliberately avoided clinical context in the original tweet to gather multiple opinions.
Image obtained from a thin, trained athlete with resting HR in 40s-50s.
A dilated IVC is commonly seen in this setting with no right heart pathology. In addition, particulate…… Image
Read 5 tweets
HV Doppler from a pt with severe group 1 pulmonary hypertension 👇

Many of us don't have ECG when doing POCUS...

Is it posible to determine this waveform components?

The answer is yes! I'll show you how I did it here

A 🧵on HV Doppler in Pulmonary Hypertension

#VExUS 1/12 Image
Normal HV is a mirror image of normal CVP waveform.

It usually has 4 waves:

2 antegrade (flow from liver to 🫀) waves (S and D)

2 retrograde (flow from 🫀 to liver) waves (A and V)

2/12 ImageImage
A frequent alteration in pts w severe PH is Severe Tricuspid Regurgitation

In severe TR, there is retrograde flow from the RV to the RA in systole. If the right atrium is not compliant, this flow reaches the HV and gives a reverse S wave!

Example from another case 👇

3/12 Image
Read 12 tweets
A straightforward, hands-on approach to Portal Vein Pulsed Wave Doppler.

Physiologic and pathologic waveforms


#doppler #PWD #echofirst #POCUS #VexUs @ButterflyNetInc

Physiologic flow should be always antegrade and hepatopetal ( towards trasducer). Could be monophasic or gently ondulating,

In doppler it should be red (get the smallest angle posible).
To Remember:

Fugal: Away

Petal: Toward

Normal velocity: 16-40 cms
Read 12 tweets
Super easy explain of physiologic Hepatic Pulsed Wave Doppler waveform.

#doppler #radiology #pocus #vexus #hemodinamics #butterflyiq @ButterflyNetInc @hepocus
After appropriate technique to get PWD of suprahepatic Veins.
Look for the 4 classic waves of the tetraphasic spectrum of the hepatic veins (a,S,v,D).

Most of the flow in the hepatic veins is hepatofugal (towards heart).
Read 11 tweets
After yesterday's #POCUS quiz, it's time to reshare these cardiac tamponade infographics.
Courtesy of @ACEP_EUS
Set of 3
See 🧵for the rest
#Nephpearls #MedEd #FOAMcc
Pulsus paradoxus #echofirst
Hepatic vein waveform changes
Read 5 tweets
Another set of cardiac #POCUS #anatomy illustrations. 🧵
#Nephpearls #FOAMed
1⃣ Parasternal long axis
2⃣ Parasternal short axis aortic valve level
3⃣ Apical 4-chamber view #POCUS
Read 7 tweets
Entendiendo la Congestión en insuficiencia cardíaca
Hilo 🧵
Taponamiento renal = más allá del entendimiento del síndrome CARDIORRENAL

Incremento de la presión venosa renal

Compresión de la vasculatura renal y de los tubulos renales
Caída de la filtración por aumento de la presión en la cápsula de Bowman
Incremento de la presión intraabdominal
Todo esto lleva a taponamiento renal !
Evolución de una teoría prerrenal a una Venorrenal
A continuación manejaremos la congestión
Read 7 tweets
#AKIConsultSeries:👨w T2DM➡️🏥 for fever, dysuria and CVA tenderness. On arrival: ⬇️BP, ⬆️Glucose, ⬆️AGMA. Dx UTI + DKA. Tx: Abx + Insulin Pump + 4 L Crystalloid + NE

After resus, pt still oliguric, Cr 3.2. NE 0.7 ug/kg/min,🧠confused, BP 85/62, HR 123, 2L O2. CRT 4 sec

Given DKA, giving additional fluids is tempting. But before we do this, its easy to do a quick assessment of fluid tolerance #POCUS

#LUS shows some B-lines (bilat)
#IVC plethoric w no respiratory collapse
#VExUS shows very pulsatile portal vein 🚨🤔

Pulse pressure is low (23!): This suggest a low cardiac output state!

Also, there are signs of fluid intolerance!

#EchoFirst: Window is suboptimal, but we see a Hyper-dynamic LV w small cavity and a turbulent flow (green color). There was no systolic RV failure

Read 12 tweets
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:
Read 21 tweets
🧵Complex #Hemodynamics in ESRD:

Middle age pt ➡️ 🏥 for syncope

HPI: Low BP during HD sessions. Does not achieve dry weight. Today she has had 6 episodes of syncope!

Last episode happened as she stood up from a chair

BP 88/62, HR 87 🧠 OK, CRT 2 sec

On #Echofist you notice this👇

During systole, flow from the LV towards the Aorta should all be blue in color! (Direction away from the probe)

This apparent change in direction (red sphere) is called Aliasing

Aliasing = Very high flow Velocity!

2/8 Image
Velocity can be quantified!

Use CW Doppler passing through the red sphere 👇

Velocity = 3.8 m/s 🚨🚨🚨 This is very fast!

Whenever you see a very fast flow, think of obstruction (similar to blocking a hose with your thumb👇)

What is causing the obstruction?

3/8 ImageImage
Read 8 tweets
Pt seen in ambulatory clinic with worsening kidney function

While the patient is sitting down (90 degrees), you notice neck pulsations!

Are they arterial or venous??

1/4 🧵
It is single peak (but not sharp)

The most striking feature is the inward movement

The breath of movement is diffuse

These are signs of venous pulsations!

Very helpful table from @AndreMansoor 👇

Thankfully we have #POCUS in clinic! I believe #POCUS can really help you improve your classic physical exam skills as it gives you immediate feedback!

Quick #VExUS reveals plethoric IVC, reverse S wave on Hepatic Vein, >100% portal vein pulsatility and mono-phasic IRVD!

Read 4 tweets
Don't miss our monthly educational review #EHJACVC @ESC_Journals!

This month by the great @ArgaizR: fluids in #AKI
Co-starring: @ThinkingCC @khaycock2

Extremely proud that our journal offers a platform to 3 great clinicians & Twitter educators. I always learn from them... Image
A strong argument is made to switch mainstream thinking in #AKI away from the fallacious concept of fluid responsiveness in all to a primary assessment of fluid tolerance.

Probably the most important thing I have learned on Twitter: #VExUS Image
Why do I like #VExUS so much? Because it really changed my everyday practice... Portal vein became part of my standard #echocardiography assessment.

And that's what we want to achieve with this review, offer something directly applicable at your bedside! Image
Read 5 tweets
A short 🧵 on hepatic vein #VExUS and key pathologies

1/ HV Anatomy & Normal Flow Profile, respiratory variation (forward flow [S,D] ⬆️ during inspiration)

Click ‘ALT’ for normal waveform description

#POCUS #MedEd #Nephrology #IMPOCUS #FOAMed The normal flow profile in ...
2/ A. Tricuspid regurgitation: Systolic flow reversal
B. Tricuspid stenosis: prolonged deceleration time of the D-wave + prominent A-wave

Click ‘ALT’ for further description

#POCUS #VExUS (A) Severe tricuspid regurg...
A. Constrictive pericarditis: expiratory ⬇️ in tricuspid flow & RV filling with associated flow reversals on HVD
B. Restrictive cardiomyopathy: prominent D reversals during inspiration
C. ⬆️RVEDP: prominent A-wave
D. RV systolic dysfunction: ⬇️ S-wave

‘ALT’ for description (A&B) A) Constrictive pericarditi...
Read 6 tweets
60 y/o ♂️ w/ ischemic heart disease & severe biventricular dysfunction. Aborted VT/VF 3x ICD shocks. Initial shock & multiorgan failure. Na 124, Cr 1.5, AST 679, ALT 765, Tbili 2.6. Una < 5mmol/L. TTE unchanged from baseline. #POCUS #vexus
What do you think is his central venous pressures based on the the IVC evaluation. Patient spontaneously breathing?
This is a very common mistake, either by tilting the transducer or getting off axis during respiratory effort. The cylinder effect is related to oblique plane insonation.
Read 9 tweets
#POCUS quiz for #VExUS enthusiasts.
Image obtained from a patient with heart failure with preserved EF. IVC 1.9 cm with 30% inspiratory collapse.
Here is the intra-renal image. Interpretation of the venous waveform?
POLL in thread 👇
#MedEd #Nephrology Image
S = systolic venous wave
D = diastolic venous wave
@khaycock2 @ArgaizR @msenussiMD You'll like it (I know u know the answer 🤫)
Read 4 tweets
Young pt ➡️ 🏥 worsening shortness of breath

PMH: ESRD. Only 1 HD session/week. However, residual urine volume has now decreased substantially

On exam: BP 134/94, 2L O2,🧠✅, elevated JVP, decreased 🫁 sounds at bases, No murmurs, very mild edema. Functional left BC AVF

Careful examination of neck veins reveals no pulsations, even with pt sitting up 🤔

What could explain the absence of venous pulse? 2/13
Answer is all of the above. JVP examination can be complicated in pts with ESRD.

In the absence of pulsations, I find #POCUS much helpful. Let's enhance our physical examination of congestion:

Read 13 tweets
CVP waveform - a variant of #VExUS #POCUS
Tracings obtained from a 38-year-old female with severe aortic stenosis and mild pulmonary hypertension who underwent aortic valve replacement. What's the difference from pre to post-op?
Se thread for answer and source.
Read 4 tweets
#AKIConsultSeries Middle-aged male ➡️🏥 for painful knee and fever. Now in shock 🚨

📂Chart review: PMH EtOH Cirrhosis, right knee arthroplasty.

It is always a good practice review previous PACS images🩻: Nodular liver, colateral vessels and prosthetic right knee

On exam: BP 72/48, HR 82, O2Sat 95%.
CRT 7 sec, 🧠somnolent, confused. No edema, no obvious ascites.

Warm, swollen and erythematous knee: Tap with obvious purulent fluid🧫

Cr 2.8 mg/dl (baseline 0.5), K 6.7, Urine 🔬: hyaline casts, some urothelial cells

Loos like hemodynamic AKI (AKA Pre-renal)

Usual causes in Cirrhosis:

🔷Distributive: Septic, "Hepatorenal physiology" 🔷Hypovolemic: Laxatives, vomiting, large volume paracentesis
🔷Congestive: Porto-pulmonary HTN, Co-existing cardiomyopathy

Read 11 tweets
#POCUS #MedTwitter #Nephpearls
Many #VExUS enthusiasts asked for a #tweetorial on image acquisition pearls. Did one b4 but time for an updated one 🧵

#1 Let's start with basics
Color Doppler identifies the flow + tells the direction (blue is away & red towards the probe [BART])
#2 👆BART holds good unless u invert the scale.
👇Pulsed wave Doppler (PWD) depicts blood flow at a certain point (sample volume) - we analyze the pattern of flow + velocity using this mode.
Above-the-baseline = flow towards the probe (like red on color)
Below = away (like blue)
While performing any Doppler study, it's important to keep in mind that the angle between US beam & blood flow determines the accuracy of velocity displayed. Parallel = best, perpendicular = worst
As #VExUS does not rely on absolute velocities, its OK not to have perfect angle
Read 28 tweets
#POCUS #VExUS consult for #hyponatremia. Elderly pt with h/o mitral valve replacement. On Bumetanide, UNa ~70 mmol/L, Uosm ~250🧵
Trace edema, JVD +, feels OK
Calling hemodynamic friends @khaycock2 @ThinkingCC @ArgaizR @msiuba @IM_Crit_ @MDBeni @siddharth_dugar Educate us!
1/ IVC
2/ 👆Consistent with elevated right atrial pressure.
👇Hepatic vein #VExUS
D-only pattern (rhythm: ventricular paced)
3/ Portal vein #VExUS
Doesn't look bad
Read 12 tweets
El número mágico de la terapia intensiva, es como los signos de la masonería, el 65!
Se empieza a romper un poco la regla de PRIMERO LO CARGAMOS DE VOLUMEN Y DESPUÉS SI…

Al parecer va mejor iniciar un manejo en conjunto de volumen y vasopresores y así evitar la sobrecarga del paciente.

Lindo lugar para el #VeXuS
Read 20 tweets
Looks like #POCUS ologists are in a mood to revive old #VExUS posts and tweetorials today.
Let me re-share the VExUS flash card(s) 🧵
1. VExUS grading live card
Hepatic vein #VExUS #POCUS
Portal vein #VExUS #POCUS
Read 5 tweets
Small thread 🧵illustrating #POCUS based hemodynamic assessment. Relatively a classic case of pulmonary HTN and right heart failure but would like to get some insights from the experts.

1/ Parasternal long axis (PSAX) showing D-sign
#VExUS #MedEd #Nephpearls #IMPOCUS
2/ Parasternal long axis (PLAX) view demonstrating RV dilatation.
One of the three musketeers is big. Don't know what I'm talking about? Here is a brief reminder: 🔗…
(Mobile thing in the RVOT is PA catheter; M-mode quiz from this morning is actually this)
3/ Apical 4-chamber view #POCUS
Note how RV is dilated - bigger than LV and forming the cardiac apex.
Inter-atrial septum is bowing to the left indicating high right atrial pressure (not unexpected).
Read 21 tweets

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