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NephSim
@Neph_Sim
, 9 tweets, 5 min read Read on Twitter
1/ The answer to our last poll: cisplatin

nephsim.com/case-13-diagno…

Below, a brief #tweetorial to walk through a simplified approach to #hyponatremia

Step 1: What type of hypoNa are we dealing with here?

Ex: Na 128 meq/L, glucose 500 mg/dL, BUN 20 mg/dL serum osm 292 mosm/kg
2/

Remember the difference between tonicity (a measure of EFFECTIVE osmoles) & osmolality (measure of both EFFECTiVE & INEFFECTIVE osmoles)

Effective osmoles cannot cross between the ECF and ICF, thus draw water across the cell membrane.

nephsim.com/image-gallery/
3/

If serum osm not low with hypoNa, we must look for the presence of ⬆️effective & ineffective osmoles (that ⬆️osmolality)

-If we find⬆️ effective osmoles ➡️ HYPERtonic hypoNa

-If we find ⬆️ INeffective osmoles ➡️ HYPOtonic hypoNa

-If neither ➡️ PseudohypoNa
4/

Back to the case from the poll. Here, we have a serum sodium of 120 meq/L and a serum osm of 268 mosm/kg ➡️ HYPOtonic hypoNa

Next step: what's the effective circulating (or arterial) volume (ECV)? Look to the urine sodium and your physical exam.

nephsim.com/case-13-diagno…
5/
Below is an #infographic outlining hypotonic hypoNa etiologies.

In our case, the pt appears volume depleted.

A urine sodium < 20 often indicates a sodium-avid state of the nephron and thus low ECV. But here the urine sodium is 53...

nephsim.com/case-13-diagno…
6/

Next question: is the hypoNa ADH-dependent? The urine osm can help us here.

A high urine osm indicates activity of ADH at the distal nephron. Here, our urine osm is elevated (744 osm/kg!) - suggesting an ADH-driven hypoNa.

nephsim.com/case-13-diagno…
7/
So what's driving the ADH? Is it "appropriate"?

Our physical exam revealed that the patient was volume depleted - which will lead to an appropriate increase in ADH release.

Now we have hypovolemic hypoNa, w/ appropriate ADH release. How do we explain the high urine Na?
8/

A renal-salt wasting state would explain both hypovolemia and high sodium in the urine, bringing us to our diagnosis of #cisplatin induced renal salt wasting.

🧂🧂🧂
9/
#Hyponatremia take home points:

1. Compare the serum osmolality to the tonicity (tonicity = EFFECTIVE osmoles only)
2. Assess the volume status (physical exam, urine Na)
3. Assess ADH activity (urine osm)

nephsim.com/case-13-diagno…

#FOAMed
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Related hashtags

#tweetorial #Hyponatremia #infographic #cisplatin #FOAMed

More from @Neph_Sim see all

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NephSim
@Neph_Sim
1/

In this #tweetorial, we'll walk through our approach to uncovering #acidbase disorders & our mnemonic #pLACO using this example:

pH 7.28, pCO2 30, pO2 75
Na 145, Cl 103, HCO3 18
Albumin 4 mg/dL

nephsim.com/acid-base/

Step 1: what does the "p" in pLACO stand for?
2/
#pLACO

The p is for pH, which tells us how acidic/basic a solution is.

Normal arterial blood pH is 7.4. Anything less than that is acidEMIC and anything greater is alkalEMIC.

In our example, the pH is 7.28. Thus, we have an acidemia.

nephsim.com/acid-base/
3/
#pLACO

Step 2: The "L" stands for ✅ labs (pCO2, HCO3).

In our example, the pCO2 is ⬇️ ( normal = 40 mm Hg). The bicarbonate is also ⬇️ (normal = 24 meq/L).

Acidemia and ⬇️bicarbonate suggest that the PRIMARY process is a metabolic acidosis.

nephsim.com/acid-base/
Read 11 tweets

Related threads

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Ellie Murray
@EpiEllie
A #tweetorial about defining your protocol for per-protocol effects, using the LIVE trial of personalized mechanical ventilation for acute respiratory distress syndrome (ARDS).

h/t @otavio_ranzani @f_g_zampieri

Original article in @LancetRespirMed👇🏼
thelancet.com/journals/lanre…
First, what is the research question?

The Lung Imaging for Ventilator Setting (LIVE) trial was designed to test if choosing ventilator settings based on lung features (focal vs non-focal) could help improve ARDS survival, relative to a one-size-fits-all ventilation approach.
Of 1080 potential participants w/ ARDS assessed for eligibility, 420 were eventually randomized to either the control arm (one-size-fits-all settings) or personalized arm (settings based on focal vs non-focal).

The treatment matrix is sorta complex, so I’m pasting it here👇🏼
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Skyler Lentz
@SkylerLentz
Tips on the mechanically ventilated ARDS and sick hypoxemic patient.

Protect the lungs from the start! See the basics below.

#Tweetorial #foamcc #foamed

Based on prior work with @mattroginski @roo_atchinson

@UVM_EM

1/
What is the definition of ARDS?

The Berlin criteria: Acute onset within one-week, bilateral opacities on CXR not explained by cardiogenic pulmonary edema, pleural effusion etc. and a PaO2/FiO2 ratio of <300 mm Hg with PEEP 5 cm H2O.

jamanetwork.com/journals/jama/…

2/
More simply in the ED or acute setting I consider anyone with bilateral infiltrates + inflammation (sepsis, pneumonia, trauma etc) + hypoxemia to be at risk for ARDS and if intubated manage them with lung protective ventilation.
3/
Read 16 tweets
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Steven Chen
@DrStevenTChen
Want to hear a joke?

What's bumpy & painful, & "read" all over?

A #tweetorial/#medthread on ERYTHEMA NODOSUM!

Now that I've lost a few hundred followers from that terrible opener😳, let's get started👇👇

#MedEd #FOAMEd #dermatology #dermtwitter #medtwitter pc: @dermnetnz
1/
Why talk about erythema nodosum (EN) in the first place? Well, most medical professional recognize it, will see it, but may need some help past that! If that's you, read on.
1st, exam: As the name implies- red nodules! It's usually on the legs, & they are often ill-defined.
2/
EN is commonly seen in young healthy pts, & women >> men. Of course, the patient's history is critical, as EN is a reactive process to something else! It's inflammation in the subQ fat (a panniculitis). The rash itself isn't dangerous, but should prompt looking for a trigger.
3/
Read 13 tweets
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Zaven Sargsyan
@sargsyanz
Beef with maintenance fluids.

This salty #tweetorial will pose some questions and explore common pitfalls of using IV fluids “for maintenance.”
Poll: how would you describe dripping 100 mL (a third of a coke can) per hour of NS or LR into a patient who has a heart rate of 100 and a high BUN?
Good choice!

If someone is volume down, give them a bolus.

“Maintenance fluids” are often the wrong choice because they’re not enough.
Read 15 tweets
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Steven Chen
@DrStevenTChen
Thanks to all for the encouragement after my first #tweetorial on SJS/TEN! I thought I'd keep the momentum going with #dermatology emergencies with a new #twearl aka #MedThread on #DRESS Syndrome, Drug Rash with Eosinophilia and Systemic Symptoms! Thanks to @dermnetnz!
1/
DRESS is a life-threatening drug reaction that, as the name implies, can cause systemic/end-organ damage. Although less flashy than SJS/TEN, it's much more common, occurring 10x more frequently! With a mortality estimated to be up to 10%, admission is usually recommended.
2/
Clinically, the name DRESS can be misleading. Let's try a quick poll:

Which of the following features is REQUIRED for the diagnosis to be made?

3/
Read 14 tweets
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Valerie Fitzhugh, MD
@DrFNA
Last night I posted this lovely gross picture; I’m now adding a couple of histologic images. Kudos to @kriyer68 and @DrAldehyde for being the first to submit the correct answer- this is indeed a synovial sarcoma! Not a bad time for a #Tweetorial #BSTPath
Synovial sarcoma is actually uncommon in joint cavities & does not recapitulate synovium in any way. Its rare amongst soft tissue sarcomas, representing only 5-10% of the cases. The disease is most prevalent in teenagers & young adults; 50% of cases are seen in pediatric patients
These most commonly present as pain in the affected site with an associated mass. In many cases the duration of symptoms is 2-5 years. They are seen most commonly in the extremities and are often associated with tendons. #BSTPath
Read 12 tweets

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