submassive PE due to liver mass leading to IVC obstruction with visible ivc clot! improved with lysis #StoweEM20 by @ThinkingCC
portal vein gas on ultrasound is more sensitive for badness (vs AXR or CT) but doesnt necessarily indicate a catastrophe! no longer “the undertakers sign” #StoweEM20 by @ThinkingCC
shock with normal LVEF on transthoracic US... TEE showed torrential MR! #StoweEM20 by @ThinkingCC
sepsis/ARDS patient treated woth crystalloid.. developed congestive nephropathy... multi-organ failure resolved with diuresis (combined diuresis loop/thiazide despite being on norepinephrine 😛) #DiuresisJedi#StoweEM20 by @ThinkingCC
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how to place a consult: you MUST understand the five stages of consultant grief.
once you can understand this painful and natural process, requesting consults will make a LOT more sense
buckle up, it can be a little rough…
🧵 1/6…
stage 1: denial
- You dont need a consult.
- You called the wrong service.
- 18 years old? consult pediatrics
- I’m not actually on call now
- Everything’s fine, just walk it off…
stage 2: anger
- you should have consulted us earlier/later
- you should have checked this test before calling us
- you’re a terrible doctor/student/human being
this is much better than MINDS (which contained ~90% hypoactive), but probably still not ideal.
(at this point, does anyone actually think that haloperidol helps with hypoactive delirium ??)
other than dilution of the patient population by patients with hypoactive delirium (who are unlikely to benefit & might conceivably be harmed by over-sedation), the methodology seems pretty solid.
I think it's time for a difficult discussion, folks.
Let's talk about CSF lactate 🫣
CSF lactate has been shown to be *superior* to traditional CSF studies in sorting out viral vs. bacterial meningitis in several studies & meta-analyses...
a subset of patients with viral meningitis will initially have a *neutrophilic* pleocytosis.
this can lead to unnecessary admissions & antibiotics
some patients are subjected to repeat LPs 😩
a low CSF lactate could avoid all of this, allowing patients to go home from the ED
CSF lactate measurement is recommended in guidelines from the United Kingdom, Europe, and France.
(it's not recommended in the ID society of America guidelines, but they're from *2004* and require revisions)