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Mark Ramzy, DO, EMT-P

1 Jan 20, 3 tweets, 5 min read

@POCUS_Society

You're going to place a central line on a hypotensive patient. 💉

You got this 💪🏽

You put the ultrasound probe on their IJ to take a look 😷👀

And you see this👇🏾

😳😱😱

#FOAMed #FOAMus #FOAMcc

@POCUS_Society @UBemSono @EM_RESUS @MaimoUltrasound @EMUGs_ @SAEMAEUS @sinaiemus

@UltrasoundMD

🌊 Turbulent Flow 🌊

Some of the many but not all causes include:
♦️Thrombi, Clots & Hypercoaguable States
♦️Vessel Stenosis & PVD (often from Atherosclerosis)
♦️Disorders affecting viscosity (PCV, Waldenstrom, etc)
♦️Sickle Cell

#FOAMed @UltrasoundMD @jeff_sono @grepmeded

@TempleEMUS

In this patient, a clot further down the IJ prevented the CVC from being placed.😕

Use caution before attempting CVC placement in patients w/this much turbulent flow & consider some underlying causes!

#FOAMed @PittIMPOCUS @TempleEMUS @ultrasoundREL @ultrasoundpod @ACEP_EUS

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More from @MRamzyDO

Mark Ramzy, DO, EMT-P

@MRamzyDO

20 Apr 20

@cameronks

The medical community is divided when it comes to treating #COVID19. Various debates/theories dominate #MedTwitter & #FOAMed. Im glad to see these discussions & our progress, however patients sometimes get caught in the middle….

@cameronks @srrezaie @emcrit @EMNerd @airwaycam

@sinaiem

This thread’s intention is to simply share observations & the experience of a #COVID19 patient code named “Halo” (yes consent received by mother) whose story might seem unique but sadly a common occurrence throughout many NYC hospitals

@sinaiem @jacobi_EM @LincolnEM @NYEmergency

@grepmeded

Halo, A mid 30 year old w/#COVID19 symptoms (Febrile/SOB) for a week presented to the ED & had this CXR👇
As ED physicians, the difficult decision of disposition has never haunted us more these days when they’re like Halo: alert, talking & do not appear clinically ill

@grepmeded

Read 15 tweets

Mark Ramzy, DO, EMT-P

@MRamzyDO

10 Apr 20

@cameronks

More of our #COVID19 experience here in #NYC:

Most if not all ICUs are full & the ED is quickly becoming an ICU. There's been a push away from early intubation for those that may not need it

1/9 #COVIDfoam #FOAMed @cameronks @srrezaie @ThinkingCC @emcrit @19criticalcare

As a result, theres a very large number of “Happy Hypoxic” patients who have been tolerating HFNC for hours & sometimes for days. SpO2 continues to remain unreliable (as do certain "traditional" exam findings of respiratory distress). PaO2s continue to correlate

2/9 #COVIDfoam

https://twitter.com/cameronks/status/1248571039073873921?s=20

The oxygen requirement these patients need is very high. Hospitals w/lower volumes of #COVID19 patients should start from now in securing the appropriate resources and have contingency plans to accommodate for this

3/9 #COVIDfoam

https://twitter.com/cameronks/status/1248571039073873921?s=20

Read 9 tweets

Mark Ramzy, DO, EMT-P

@MRamzyDO

5 Apr 20

@cameronks

From experience in our #COVID19 ICU so far:

What started as an HFNC ICU has quickly turned into an ARDS unit treating iatrogenic ALI from patients being intubated

#COVIDfoam #FOAMed #FOAMcc @cameronks @PulmCrit @ThinkingCC @srrezaie @First10EM @gattinon @precordialthump

1/12

As physicians we see a low SpO2 combined with a low PaO2 & the knee jerk reaction is early intubation instead of assessing patient's overall clinical picture including their work of breathing & mental status. Here's a walk through what happens after...

2/12 #COVIDfoam #Covid_19

Following intubation, patients are put on higher PEEPs which combined w/ACE-receptor effects of virus worsens their already slightly elevated creatinine. Higher PEEPs causing increased thoracic pressure understandably leads to hypotension so patients are then given fluids

3/12

Read 12 tweets

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