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𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 💊

@PulmCrit

Sep 14, 2020 • 4 tweets • 3 min read • Read on X

three short chapters on gastrointestinal hypo-motility in critical care.
💣this topic often gets *ignored* until there's a serious complication
💣early attention to motility can avoid iatrogenesis & facilitate recovery...
(thread #1/4)

ICU gastroparesis
🤮 manifests as tube feed intolerance (but don't assume that feeding intolerance = gastroparesis!)
🤮 a post-pyloric feeding tube can treat this nicely. otherwise erythromycin +/- metoclopramide
🤮 treat this- don't just watch/wait (#2/4)
emcrit.org/ibcc/gastropar…

ICU ileus
🤮prevention is key- avoid opioids, early enteral nutrition, early mobility🏃
🤮NG drainage *only* if needed for symptomatic relief
🤮prokinetic meds don't work, but *oral* naloxone might help among patients on significant opioid doses (#3/4)
emcrit.org/ibcc/ileus/

colonic pseudoobstruction (a.k.a. Oglivie's syndrome)
💩 progressive dilation of the colon with risk of perforation
💩 mainstay of therapy is IV neostigmine
💩 get comfortable treating this - early neostigmine may prevent progression (#4/4)
emcrit.org/ibcc/oglivie/

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More from @PulmCrit

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 💊

@PulmCrit

Oct 26

Critical interactions for the critical care cardiologist: An anthology of the tortured pharmacist's department

- @TaniaAhuja at #critcarecards24

@TaniaAhuja who should get AV nodal blockers?

Diltiazem is contraindicated in shock.

**If you don't know the EF, may avoid.**

Diltiazem and riveroxiban may interact as well.

- @TaniaAhuja at #critcarecards24

@TaniaAhuja diltiazem plus riveroxiban interaction may increase bleeding

- @TaniaAhuja at #critcarecards24

Read 6 tweets

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 💊

@PulmCrit

Oct 26

Low slow and trying to crash

CCB & Bbl intoxication.

Getting things done is tough! A really sick CCB/BBl intoxication challenges this.

- @emcrit at #critcarecards24

@emcrit Start with calcium, although it probably don't do a ton. May follow this with a calcium infusion if there is sufficient IV access.

- @emcrit at #critcarecards24

@emcrit Intubate early before hemodynamics truly fall apart.

- @emcrit at #critcarecards24

Read 9 tweets

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 💊

@PulmCrit

Oct 25

Why do I deviate from ACLS?

- @mdonnino at #critcarecards24

@mdonnino Do you resume CPR after shock? Yeap.

In 2005 the algorithm changed from stacked shocks to a single shock followed by waiting for 2 minutes to see what is going on.

No solid evidence that this was the correct approach.

- @mdonnino at #critcarecards24

@mdonnino Years after implementation: the new approach actually seemed to cause worse outcomes (not statistically significant)

- @mdonnino at #critcarecards24

Read 4 tweets

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 💊

@PulmCrit

Oct 25

More on RV failure:

Acute RVMI: loading can be helpful because we want to raise the RV pressure higher than the PA pressure to cause blood to flow downhill.

- @Chrisotpher Barnett at #critcarecards24

Chronic pulmonary artery hypertension: RV is *chronically* adapted

Volume loading may help push patients into the RV death spiral.

- Chrisotpher Barnett at #critcarecards24

In chronic RV dysfunction, function may often be optimized by fluid removal.

this may additionally avoid systemic congestion!

- @ChrisBarnettMD at #critcarecards24

Read 6 tweets

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 💊

@PulmCrit

Oct 25

1st talk: RV dysfunction by @Sam_Brusca at #critcarecards24

RV contracts in multiple mechanisms.

LV contraction indirectly contributes 40% of the stroke volume of the RV!

- RV-PA coupling may fail with RV dilation, but this is difficult to assess at the bedside

- @Sam_Brusca at #critcarecards24

PAPI as a marker of RV-PA coupling!

cutoff may depend on context

RV MI: unconditioned PAPI decouples at <1

PAH: PAPI cutoff for worse outcomes may be higher

Read 7 tweets

𝙟𝙤𝙨𝙝 𝙛𝙖𝙧𝙠𝙖𝙨 💊

@PulmCrit

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

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