Thread by @EAFischer

1/ Volume Assessment… … is hard

Physical exam for hypovolemia, a thread

2/ Is the above patient?

3/ What do we mean by “𝗱𝗿𝘆”? By 𝘃𝗼𝗹𝘂𝗺𝗲 𝘀𝘁𝗮𝘁𝘂𝘀?

𝗗𝗲𝗵𝘆𝗱𝗿𝗮𝘁𝗲𝗱 is often ~ hypertonicity / intracellular volume contraction

𝗩𝗼𝗹𝘂𝗺𝗲 𝗱𝗲𝗽𝗹𝗲𝘁𝗶𝗼𝗻 is ↓extracellular volume w/ blood volume contraction
bit.ly/3d1GWhh

4/ But are we really wondering 𝘄𝗵𝗲𝘁𝗵𝗲𝗿 𝗼𝗿 𝗻𝗼𝘁 𝘁𝗼 𝗴𝗶𝘃𝗲 𝗜𝗩𝗙?

Is my pt 𝗳𝗹𝘂𝗶𝗱 𝗿𝗲𝘀𝗽𝗼𝗻𝘀𝗶𝘃𝗲 or at least 𝗳𝗹𝘂𝗶𝗱 𝘁𝗼𝗹𝗲𝗿𝗮𝗻𝘁, bit.ly/3gY2CvU?

𝘈𝘯𝘥 𝙬𝙝𝙖𝙩 𝙛𝙡𝙪𝙞𝙙 𝘵𝘰 𝘨𝘪𝘷𝘦, 𝘣𝘪𝘵.𝘭𝘺/3𝘨𝘘8𝘦𝘵𝘱

A separate discussion

5/ Focus: hypertonicity, 𝗧𝘂𝗿𝗴𝗼𝗿 & 𝗔𝘅𝗶𝗹𝗹𝗮𝗿𝘆 𝗦𝘄𝗲𝗮𝘁, per McGee, bit.ly/3hf3dcT ➨ mod helpful

𝘐𝘨𝘯𝘰𝘳𝘦 𝘮𝘶𝘤𝘰𝘶𝘴 𝘮𝘦𝘮𝘣𝘳, 𝘵𝘰𝘯𝘨𝘶𝘦 𝘧𝘶𝘳𝘳𝘰𝘸𝘴, 𝘴𝘶𝘯𝘬𝘦𝘯 𝘦𝘺𝘦𝘴. 𝘋𝘪𝘧𝘧𝘪𝘤𝘶𝘭𝘵 𝘵𝘰 𝘴𝘵𝘢𝘯𝘥𝘢𝘳𝘥𝘪𝘻𝘦 =𝘱𝘦𝘳𝘧𝘰𝘳𝘮𝘢𝘯𝘤𝘦

6/ 𝗔𝘅𝗶𝗹𝗹𝗮𝗿𝘆 𝗦𝘄𝗲𝗮𝘁 performed 2 ways
1.Apply 𝗽𝗿𝗲𝘄𝗲𝗶𝗴𝗵𝗲𝗱 𝘁𝗶𝘀𝘀𝘂𝗲 to the patients’ right axilla for 15 min, weigh after bit.ly/2TRAjY5
2.Use 𝗺𝗼𝗶𝘀𝘁𝘂𝗿𝗲 𝗶𝗺𝗽𝗲𝗱𝗮𝗻𝗰𝗲 𝗺𝗲𝘁𝗲𝗿 was applied to axilla bit.ly/3gP84Co
NOT PRACTICAL

7/ 𝗧𝘂𝗿𝗴𝗼𝗿, the last PE finding standing?
How to:
Positive when >3 sec after 3 sec of pinching subclavicular* skin (bit.ly/3vLojVm)
𝘛𝘩𝘪𝘴 𝘱𝘵 𝘩𝘢𝘥 𝘥𝘪𝘢𝘳𝘳𝘩𝘦𝘢 𝘢𝘯𝘥 𝘕𝘢 157. 𝘋𝘪𝘥 𝘐 𝘯𝘦𝘦𝘥 𝘵𝘶𝘳𝘨𝘰𝘳 𝘵𝘰 𝘤𝘰𝘯𝘧𝘪𝘳𝘮 𝘴𝘩𝘦 𝘯𝘦𝘦𝘥𝘦𝘥 𝘋5𝘞?

8/ What about 𝗼𝗿𝘁𝗵𝗼𝘀𝘁𝗮𝘁𝗶𝗰𝘀?

For hypovolemia not helpful (bit.ly/3vLojVm)

9/ Early studies phlebotomized (i.e.
𝗯𝗹𝗼𝗼𝗱 𝗹𝗼𝘀𝘀, not hypertonicity) moderate (450-630 mL) to large (630 – 1150 mL) amounts of blood

≥20 mm Hg ↓ SBP was 9% sensitive for moderate blood loss! Better maybe actually a pulse ↑≥30/ or just subjective severe dizziness

10/ What about 𝗰𝗮𝗽𝗶𝗹𝗹𝗮𝗿𝘆 𝗿𝗲𝗳𝗶𝗹𝗹 𝘁𝗶𝗺𝗲?

For hypovolemia it might be “useless” bit.ly/2UwJ2iN

11/ CRT to assess 𝗽𝗲𝗿𝗶𝗽𝗵𝗲𝗿𝗮𝗹 𝗽𝗲𝗿𝗳𝘂𝘀𝗶𝗼𝗻 maybe not.

But should we measure it as in ANDROMEDA-SHOCK bit.ly/3qjRo9j?
•Firm pressure to ventral right index finger with
𝗴𝗹𝗮𝘀𝘀 𝘀𝗹𝗶𝗱𝗲 for 10 sec
•Nl skin color with chronometer, CRT >3 sec = abnl

12/ A word on volume responsiveness, it doesn’t seem like any exam maneuver discussed is predictive ☹️(bit.ly/3j3Y2Pm)
The closest thing might be a passive leg raise, but this depends on dynamic assessments of cardiac output (or surrogates)

https://twitter.com/NephroP/status/1266454794748801024?s=20

13/ goodybedside.com/gim/volume/

And volume assessment, next level:

https://twitter.com/manoj_wickram/status/1367967680951689219