Ernest Fischer, MD Profile picture
#Hospitalist | APD | #POCUS | #CCeEXAM testamur | Proceduralist | Allan J. Goody Bedside Medicine Series | Medstar Georgetown University Hospital

Jun 23, 2021, 14 tweets

1/ Volume Assessmentโ€ฆ โ€ฆ is hard

Physical exam for hypovolemia, a thread

2/ Is the above patient?

3/ What do we mean by โ€œ๐—ฑ๐—ฟ๐˜†โ€? By ๐˜ƒ๐—ผ๐—น๐˜‚๐—บ๐—ฒ ๐˜€๐˜๐—ฎ๐˜๐˜‚๐˜€?

๐——๐—ฒ๐—ต๐˜†๐—ฑ๐—ฟ๐—ฎ๐˜๐—ฒ๐—ฑ is often ~ hypertonicity / intracellular volume contraction

๐—ฉ๐—ผ๐—น๐˜‚๐—บ๐—ฒ ๐—ฑ๐—ฒ๐—ฝ๐—น๐—ฒ๐˜๐—ถ๐—ผ๐—ป is โ†“extracellular volume w/ blood volume contraction
bit.ly/3d1GWhh

4/ But are we really wondering ๐˜„๐—ต๐—ฒ๐˜๐—ต๐—ฒ๐—ฟ ๐—ผ๐—ฟ ๐—ป๐—ผ๐˜ ๐˜๐—ผ ๐—ด๐—ถ๐˜ƒ๐—ฒ ๐—œ๐—ฉ๐—™?

Is my pt ๐—ณ๐—น๐˜‚๐—ถ๐—ฑ ๐—ฟ๐—ฒ๐˜€๐—ฝ๐—ผ๐—ป๐˜€๐—ถ๐˜ƒ๐—ฒ or at least ๐—ณ๐—น๐˜‚๐—ถ๐—ฑ ๐˜๐—ผ๐—น๐—ฒ๐—ฟ๐—ฎ๐—ป๐˜, bit.ly/3gY2CvU?

๐˜ˆ๐˜ฏ๐˜ฅ ๐™ฌ๐™๐™–๐™ฉ ๐™›๐™ก๐™ช๐™ž๐™™ ๐˜ต๐˜ฐ ๐˜จ๐˜ช๐˜ท๐˜ฆ, ๐˜ฃ๐˜ช๐˜ต.๐˜ญ๐˜บ/3๐˜จ๐˜˜8๐˜ฆ๐˜ต๐˜ฑ

A separate discussion

5/ Focus: hypertonicity, ๐—ง๐˜‚๐—ฟ๐—ด๐—ผ๐—ฟ & ๐—”๐˜…๐—ถ๐—น๐—น๐—ฎ๐—ฟ๐˜† ๐—ฆ๐˜„๐—ฒ๐—ฎ๐˜, per McGee, bit.ly/3hf3dcT โžจ mod helpful

๐˜๐˜จ๐˜ฏ๐˜ฐ๐˜ณ๐˜ฆ ๐˜ฎ๐˜ถ๐˜ค๐˜ฐ๐˜ถ๐˜ด ๐˜ฎ๐˜ฆ๐˜ฎ๐˜ฃ๐˜ณ, ๐˜ต๐˜ฐ๐˜ฏ๐˜จ๐˜ถ๐˜ฆ ๐˜ง๐˜ถ๐˜ณ๐˜ณ๐˜ฐ๐˜ธ๐˜ด, ๐˜ด๐˜ถ๐˜ฏ๐˜ฌ๐˜ฆ๐˜ฏ ๐˜ฆ๐˜บ๐˜ฆ๐˜ด. ๐˜‹๐˜ช๐˜ง๐˜ง๐˜ช๐˜ค๐˜ถ๐˜ญ๐˜ต ๐˜ต๐˜ฐ ๐˜ด๐˜ต๐˜ข๐˜ฏ๐˜ฅ๐˜ข๐˜ณ๐˜ฅ๐˜ช๐˜ป๐˜ฆ =๐˜ฑ๐˜ฆ๐˜ณ๐˜ง๐˜ฐ๐˜ณ๐˜ฎ๐˜ข๐˜ฏ๐˜ค๐˜ฆ

6/ ๐—”๐˜…๐—ถ๐—น๐—น๐—ฎ๐—ฟ๐˜† ๐—ฆ๐˜„๐—ฒ๐—ฎ๐˜ performed 2 ways
1.Apply ๐—ฝ๐—ฟ๐—ฒ๐˜„๐—ฒ๐—ถ๐—ด๐—ต๐—ฒ๐—ฑ ๐˜๐—ถ๐˜€๐˜€๐˜‚๐—ฒ to the patientsโ€™ right axilla for 15 min, weigh after bit.ly/2TRAjY5
2.Use ๐—บ๐—ผ๐—ถ๐˜€๐˜๐˜‚๐—ฟ๐—ฒ ๐—ถ๐—บ๐—ฝ๐—ฒ๐—ฑ๐—ฎ๐—ป๐—ฐ๐—ฒ ๐—บ๐—ฒ๐˜๐—ฒ๐—ฟ was applied to axilla bit.ly/3gP84Co
NOT PRACTICAL

7/ ๐—ง๐˜‚๐—ฟ๐—ด๐—ผ๐—ฟ, the last PE finding standing?
How to:
Positive when >3 sec after 3 sec of pinching subclavicular* skin (bit.ly/3vLojVm)
๐˜›๐˜ฉ๐˜ช๐˜ด ๐˜ฑ๐˜ต ๐˜ฉ๐˜ข๐˜ฅ ๐˜ฅ๐˜ช๐˜ข๐˜ณ๐˜ณ๐˜ฉ๐˜ฆ๐˜ข ๐˜ข๐˜ฏ๐˜ฅ ๐˜•๐˜ข 157. ๐˜‹๐˜ช๐˜ฅ ๐˜ ๐˜ฏ๐˜ฆ๐˜ฆ๐˜ฅ ๐˜ต๐˜ถ๐˜ณ๐˜จ๐˜ฐ๐˜ณ ๐˜ต๐˜ฐ ๐˜ค๐˜ฐ๐˜ฏ๐˜ง๐˜ช๐˜ณ๐˜ฎ ๐˜ด๐˜ฉ๐˜ฆ ๐˜ฏ๐˜ฆ๐˜ฆ๐˜ฅ๐˜ฆ๐˜ฅ ๐˜‹5๐˜ž?

8/ What about ๐—ผ๐—ฟ๐˜๐—ต๐—ผ๐˜€๐˜๐—ฎ๐˜๐—ถ๐—ฐ๐˜€?

For hypovolemia not helpful (bit.ly/3vLojVm)

9/ Early studies phlebotomized (i.e.
๐—ฏ๐—น๐—ผ๐—ผ๐—ฑ ๐—น๐—ผ๐˜€๐˜€, not hypertonicity) moderate (450-630 mL) to large (630 โ€“ 1150 mL) amounts of blood

โ‰ฅ20 mm Hg โ†“ SBP was 9% sensitive for moderate blood loss! Better maybe actually a pulse โ†‘โ‰ฅ30/ or just subjective severe dizziness

10/ What about ๐—ฐ๐—ฎ๐—ฝ๐—ถ๐—น๐—น๐—ฎ๐—ฟ๐˜† ๐—ฟ๐—ฒ๐—ณ๐—ถ๐—น๐—น ๐˜๐—ถ๐—บ๐—ฒ?

For hypovolemia it might be โ€œuselessโ€ bit.ly/2UwJ2iN

11/ CRT to assess ๐—ฝ๐—ฒ๐—ฟ๐—ถ๐—ฝ๐—ต๐—ฒ๐—ฟ๐—ฎ๐—น ๐—ฝ๐—ฒ๐—ฟ๐—ณ๐˜‚๐˜€๐—ถ๐—ผ๐—ป maybe not.

But should we measure it as in ANDROMEDA-SHOCK bit.ly/3qjRo9j?
โ€ขFirm pressure to ventral right index finger with
๐—ด๐—น๐—ฎ๐˜€๐˜€ ๐˜€๐—น๐—ถ๐—ฑ๐—ฒ for 10 sec
โ€ขNl skin color with chronometer, CRT >3 sec = abnl

12/ A word on volume responsiveness, it doesnโ€™t seem like any exam maneuver discussed is predictive โ˜น๏ธ(bit.ly/3j3Y2Pm)
The closest thing might be a passive leg raise, but this depends on dynamic assessments of cardiac output (or surrogates)

And volume assessment, next level:

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