Elderly ♂️, PMH of T2DM and CKD.

Suspected COVID-19 because of shortness of breath. Sent to the COVID-19 ED service.

No fever, no cough. No chest pain. Physical exam with patient sitting up (almost 90°):

¿Is this neck pulse arterial or venous? 1/8
Pulse is diffuse and the most striking feature is inward movement. I borrowed this table from @AndreMansoor's must-see lecture on Jugular Venous Pulse **Curiously, notice that there is a single peak instead of the expected double peak 🤔 2/8
I had to get my probe! #POCUS showed severely reduced EF with anterior wall motion abnormality and normal RV function.

EKG showed anterior ST segment changes. This was ACS! Cath lab was activated

#VExUS showed plethoric IVC, reverse hepatic vein flow and portal vein with >50% pulsatility.

#VExUS = 3

Hepatic vein Doppler flow reversal explains why there was only ONE peak on JVP. There is only one antegrade wave!

🚨Next is for Doppler nerds only:

NO ECG on #POCUS machine available to determine the origin of flow reversal on HV.

So, it could either be S wave reversal or D wave reversal. **Patient was in sinus rhythm 5/8
S wave reversal is only observed in cases of severe RV disfunction or severe tricuspid regurgitation... None were present: 6/8
So this leads me to speculate that septal motion during LV DIASTOLE is impeding RV filling.

Given anterior wall was completely akinetic, there was septal bulging into the RV in diastole:

So I believe HV shows D wave reversal! ping @NephroP @Thind888 @msenussiMD

In conclusion:

-This was not COVID-19
-Physical exam rules!
-#POCUS definitely enhanced examination
-Single peak on JVP suggests flow reversal (either X or Y descent is missing)
-This may be an interesting cause of diastolic wave reversal on hepatic vein doppler


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More from @ArgaizR

6 Oct
A case for hepatic vein Doppler lovers:

ECG tracing not abvailable on the ultrasound machine (I tried, I swear)

Can we still interpret this HV waveform without ECG?

I speculate we can!

I'll try to do it step by step: 1/7
What can we tell?

For one, there are 2 retrograde waves and 1 antegrade wave.

Given the patient was in sinus rhythm, then one of the retrograde waves MUST be an A wave! 2/7
Given HV waveform sequence should always be A-S-D, AND A wave is always retrograde:

Then this leaves only 2 possibilities: There could either be S wave reversal or D wave reversal 3/7
Read 8 tweets
5 Oct
Back on COVID-19 service this month

Went to see this patient with "increased respiratory drive despite high dose sedation and NMB". This is the vent: 1/4
Looking at the patient's monitor, the respiratory curve seems oddly coincident with heart rate: 2/4
Inspiratory pause reveals NO respiratory drive and several cardiogenic oscillations! 3/4
Read 4 tweets
14 May
🧵 AKI and #COVID19

68 yo ♂️ PMH obesity, HTN, CAD w stent, OSA, T2DM
➡️ ED w SOB + fever 39.9°C. Poor oral intake

RR 40, Sat 94% Room Air, BP 157/74 HR 124. Alert. Bibasilar crackles

Labs: Cr 1.3 (baseline 0.8), WBC 10, K 5.4, HCO3 17, CK 184. UA and CXR👇 (case from @NEJM)
How would you manage this AKI initially? What is the likely cause of AKI in patients with #COVID19? (this last question discussed in thread 🧵)
No easy answer except to say that FENa is very unlikely to be useful. It is not unreasonable to try fluids for AKI in the setting of perceived hypovolemia. However, this gets complicated when the potential for worsening ARDS exists. I'll try to tackle the answers one by one 💪
Read 17 tweets
11 May
Which of these patients has a more severe degree of venous congestion? #VExUS Thread 🧵 about the Portal Vein (1/17)
Video above shows IVC in short axis, long axis and diameter (from left to right)

Which of these patients has a more severe degree of venous congestion? (2/17)
Abdominal IVC size depends on the difference between CVP and IAP. At a constant IAP, IVC size will increase proportionally to CVP until it reaches the flat part of it's compliance curve. (Great thread by @Thind888 here: ) (3/17)
Read 18 tweets
28 Apr
Dr. Gattinoni or: How I Learned to Stop Worrying about P-SILI and Love Furosemide

WEIRD THREAD 🧵 About the blood-gas barrier and #COVID19 (1/9)
Clinical Case: A 4 year old Thoroughbred Horse with a history of recurrent racing-associated epistaxis comes to your office complaining of decreased track performance. He wants to know if there is anyway to prevent this from happening (2/9)
What treatment would you recommend? (3/9)
Read 10 tweets
22 Apr
“If you think an awake patient having normal mental status and a basic metabolic panel is available needs a blood gas, you’re wrong. You need the blood gas done on yourself because you may be brain dead.” quote from Dr. Corey Slovis (1/7)
A few days ago I ran this poll. Most of you chose not to get an ABG. This is in fact what I did (and disappointed the consulting team) Pt had no comorbidities, and HCO3 was normal. (2/7)
Pt not on opioids and no COPD should have a preserved respiratory drive, thus hypercapnia should NOT occur unless exhaustion. Instead, I monitored my pt closely and that same evening O2sat much better. A few days later pt was discharged home. Not a single ABG was drawn. (3/7)
Read 7 tweets

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