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𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊 Profile picture
@PulmCrit
Jan 27, 2020 • 5 tweets • 6 min read • Read on X
Scrolly
RV resuscitation! screen for RV failure with POCUS (and records if you have em) #thepeoplesventricle #StoweEM20 by @mattroginski ImageImageImage
incorrect probe rotation can cause RV size to be underestimated! Matt’s own echo has great TAPSE #humblebrag #StoweEM20 by @mattroginski ImageImage
badness:
D sign on short axis
RV dilation in subcostal
#StoweEM20 by @mattroginski ImageImage
signs of severe badness: with bubble injection:
- bubbles take forever to clear (CO is aweful, blood isnt going anywhere)
- right to left shunt
#StoweEM20 by @mattroginski Image
- juditious volume management
- early pressor
- arrhythmia tx
- avoid intubation if possible
#StoweEM20 by @mattroginski ImageImageImageImage

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More from @PulmCrit

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊 Profile picture
Dec 17, 2023
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
Read 6 tweets
𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊 Profile picture
Nov 24, 2023
I’m gonna myth-bust this myth-busting slide on the use of bicarb.

the slide says to use bicarb for hyperkalemia “only in cardiac arrest??”

there is evidence on this and I think it’s possible to make a more accurate statement… 🧵
the problem is that people ask the wrong question: “does bicarb work for hyperkalemia”

bad question.

any systemic analysis based on this question is a failure.

this would be like asking “does sodium chloride work for cerebral edema”

well, it depends… on the concentration!
hypertonic sodium bicarb (in the USA = 50 mEq in 50 cc) doesn’t work for hyperkalemia

this has been tested in RCTs and it doesnt work

hypertonic fluids pull fluid & K out of cells (“solute drag”) and this prevents hypertonic bicarb from working for hyperkalemia
Read 5 tweets
𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊 Profile picture
Oct 27, 2022
another haloperidol thread 😃

this fresh pro-con debate on the use of IV haloperidol is important reading (even for folks not working in the emergency department).

(is there any neuroactive medication that people don't have passionate opinions about? 🤣) ImageImageImageImage
from the ICU perspective, the recent AID-ICU trial shows that IV haloperidol is safe in the ICU.

of course, this *assumes* that it's used wisely (with attention to electrolytes and QT)

(hint: when in doubt, give IV magnesium along with the haloperidol)

as @SkylerLentz et al. discuss, haloperidol is generally preferred over benzodiazepines for agitation in the ICU.

as a general rule of thumb, *any* time you're tempted to use benzodiazepines in the ICU - consider whether haloperidol might be a better option.

benzos are a trap:
Read 5 tweets
𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊 Profile picture
Oct 26, 2022
hot take on the AID-ICU trial of haloperidol for management of delirium in ICU 🔥

this is the largest MC-RCT to date on haloperidol for treatment of delirium (in comparison, MINDS enrolled 192 patients in the haloperidol group).

nejm.org/doi/full/10.10…
55% of patients had hyperactive delirium.

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.
Read 11 tweets
𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊 Profile picture
Aug 17, 2022
I think this paper by the Nielsen group on the use of CT scans to neuroprognosticate after cardiac arrest may be a game-changer.

But it will take a few tweets to explain why... 🧵

pubmed.ncbi.nlm.nih.gov/35931271/
prognostication after cardiac arrest involves a structured series of tests performed over time.

this may vary a bit between patients and institutions.

most often, decisions center around the trifecta:
🔺serial clinical examination
🔺continuous EEG
🔺MRI
MRI is the weak link:

🖇️ least robust evidence
🖇️ interpretation is subjective
🖇️ logistically challenging (eg pacemaker)

MRI can help if there is *no* anoxia, or if there is an unexpected *alternative* dx.

MRI isn't great at sorting out bad anoxia from moderate anoxia.
Read 8 tweets
𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 (he/him) 💊 Profile picture
Aug 15, 2022
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)
Read 6 tweets

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