1/🧵🎥 MAJOR TIPS about #Liver Disease
Why do we ask pts to “hold up traffic”? When people get severe liver disease, “asterixis” is a finding on exam we often see.

What does it mean?
#MedTwitter #NurseTwitter #TipsforNewDocs #Addiction
2/ Asterixis indicates that toxins like ammonia have built up in the body because the scarred liver no longer filters them out. The brain cells no long function normally (#Delirium or Hepatic #Encephalopathy) & can no longer control muscle movements like posture!
3/ These same toxin cause vessels to dilate and develop problems with blood flow in the skin and lungs. A skin finding is called “spiders.” They look like a multi-legged spider, right? It’s a tip-off.
4/ The Papal Sign is another weird thing in liver disease. Patient’s hands may develop an involuntary scarring that leads the 4th and 5th finger to bend down like the Pope giving a blessing.
5/ The abdomen gets full of ascitic fluid that we drain with a needle. Look how protuberant this belly is and a picture of what the drained fluid can look like. What does it mean? Well we have to study it with lab data.
6/ We look for infection called “SBP” – spontaneous bacterial peritonitis. Most doctors don’t know the origin of the 250 WBC neutrophils as the best cut-off. #CLASSIC paper: bit.ly/3yLnGNh
7/ The other #CLASSIC thing we need to know is the Runyon Criteria showing the best cut-off for thicker fluid indicating infection or cancer is a “SAAG” < 1.1 (Serum Ascites Albumin Gradient) vs. >1.1 meaning portal hypertension: bit.ly/2VxPYg4
8/ Patients often suffer from #DeliriumTremens or DTs. It can be from alcohol withdrawal. Most people use benzos, but they aren’t evidence based. A new study recommended phenobarbital, but really we need to do a proper randomized trial!
Last tip: Resist benzodiazepines for DTs. There are better ways than “converting” everyone to quiet delirium. For DTs, I use dex & clonidine (alpha-2 agonists) - an extrapolation based on Dahlia Study data: bit.ly/3yDIwhI

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More from @WesElyMD

13 Aug
1/🧵#Covid19 is a disease of blood vessels that can affect your lungs, heart, brain, or any organ. Blood clotting sucks life from vital organs. This pt asked to have her story shared so that others may learn & seek #Vaccination. COVID caused blockage of blood to her arms & legs.
2/ During her acute illness, you can see that she had wounds that resembled BURN injury. It took #nurses many hours each day to change her wounds. I am being especially careful here only to show you images that are bandaged to avoid traumatizing anyone.
3/ (trigger warning on image)
As the illness progressed, it became clear that she was going to live, and we were all thrilled. Still, it was sad to think that this young woman would lose her hands and feet as they continued to dry up, lifeless and still.
Read 13 tweets
12 Aug
1/🧵 How Contagious is #Delta? @NPRHealth
Let’s compare Ro (R nought) i.e. in a gathering of all vulnerable people, how many get infected? Now some math!👇

Ebola/Flu = 2
Original #COVID19 = 3
#DeltaVariant COVID = 6 to 7
Chicken Pox = 10

2/ The difference between R0 of 3 and 6 is massive. With original COVID, 1 person infects 3 who infects 3 more. After 2 rounds, cases would rise by nine (3 x 3 = 9). After 3 rounds, cases rise by 27 (3 x 3 x 3 = 27)…
3/ But with delta, 1 person infects 6, who each infect 6 more people. So after 2 rounds, there are 36 (6 x 6 = 36) and after 3 it surges to 216 (6 x 6 x 6 = 216).

Ro of 7 gives you 343!
Read 5 tweets
11 Aug
1/🧵🎥 The #COVID19 ICU: an Insider’s look behind the curtain of our conversations with patients.
From my vantage point, there are TWO ROADS. Whether we meet depends on which one is chosen…see this video and read a real patient conversation👇

2/ Two Roads:

1. Get a #vaccine & >99% you won’t have me as your doctor.

2. Don’t get a vaccine & #DeltaVariant’s SUPER-VELCRO Spike Protein gets to decide your fate.
3/ If you don’t get a vaccine and then go to #DisneyWorld or the mall, & get #Delta infection (as multiple people in my life did recently)…

THIS is the conversation we may have…
Read 12 tweets
10 Aug
1/🧵 Why have #COVID19 hospital admissions skyrocketed? 🗣
The virus’s spike protein acts like VELCRO in our airway. #DeltaVariant has modified the #SpikeProtein to make it SUPER-VELCRO. When exposed, you’re way more apt to get infected.
#Yale Press: bit.ly/3lKvJqs
2/ “In a completely unmitigated environment—where no one is vaccinated or wearing masks—the average person infected with original coronavirus will infect 2.5 others. In the same environment, #Delta infects >4 other people & grows more quickly.”
3/ Additionally, once the infection takes root in you (most often a person NOT #vaccinated), it has modified itself to increase viral shedding 1000X (ie, 1,000 virions for every 1 that was shed with original SARS-CoV-2.

Read 8 tweets
6 Aug
1/🧵🎥 Leading #COVID19 ICU Doctor @DavidJanz5 in New Orleans, the epicenter of U.S. #DeltaVariant surge, testified before US Senate Committee on Health, Education & Labor. Here is what he said: “Studies of #FrontLine workers caring for COVID-19 patients have shown…👇
2/ that the risk for the development of #mentalhealth problems (#PTSD #Depression) are like 9/11 Terrorist Attacks & Hurricane Katrina. Recent research shows that over 1 in 3 healthcare workers are experiencing anxiety, depression & post-traumatic stress disorder.
3/ Symptoms of #burnout are experienced by over half of critical care physicians. This is the state of the workforce asked to return to the #COVID19 #frontlines for a second, third, and now fourth wave.
Read 9 tweets
5 Aug
1/🧵Fluids in sepsis: When a patient’s blood pressure is too low and they are in shock, as happens all the time with #COVID19 viral #sepsis, we give fluids. This @bmj_latest figure👇makes a bit of sense of where the fluid goes. Let me unpack a bit more…

2/ 👇 @bmj_latest
We talk about 2 categories of fluids: Crystalloids & Colloids. For crystalloids think “thin fluid like salt water with sugar.” For colloid think “thick fluid with lots of protein like albumin.” The figure shows that crystalloids leak out of the blood vessels…
3/ while colloid stays in the blood vessels. But there are several other important teaching points beyond what the figure shows.
✅ If a person has a lot of edema, as we see in heart, kidney & liver failure, colloids pull fluid into our vessels & ⬆️ blood volume to end shock…
Read 8 tweets

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