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Mourad H Senussi, MD, MS

16 Oct, 8 tweets, 4 min read

*Hyperdynamic LV: Harbinger of Doom*

This clincial scenario has played out before my eyes on multiple occasions

Echo performed on a pt with undifferentiated shock

"EF > 70%...hyperdynamic.. all good."

A hyperdynamic LV is more sinister than you may think. Lets find out why..

Consider why the LV would be hypercontractile and avoid the knee jerk reflex to assume that it is ONLY due to hypovolemia/hemorrhage i.e decreased RV preload/low mean systemic filling pressure .

Start thinking in terms of LV preload.
1. RV failure
2. Mitral regurgitation
3. VSD
4. Vasodilated state

You need to actively rule out these conditions in the right clinical context.

Multiple studies in septic pts have shown worse outcomes with a hypercontractile LV. But why?

Likely,
1. Reflexive overjudicious IVFs -->organ cogestion, dysfunction and ultimate demise.

2. Reflective of profound inflamm response and vasodilation with severe infection.

3. Anchor bias. We fail to rule out other causes of a hyperdynamic LV

Consider this thought experiment

1. Pt with baseline EF 30 %
2. Pt is septic and vasodilated
3. Hyperdynamic (70%) because afterload is decreased
4. As pt recovers (or vasopressors) afterload increases
5. EF will appear to worsen!

Understanding loading conditions is crucial

In conclusion,
1. Hyperdynamic LV is a bad omen
2. Determine why the LV isn't "seeing" much stroke volume
3. Common causes of decreased LV preload: RV failure, MR, vasodilated states, decreased RV preload
3. EF is not the same as stroke volume. Loading conditions are crucial.

@IM_Crit_

@IM_Crit_ @msiuba @NephroP @MansourKhunaizi @iceman_ex @ArgaizR @nomadic_medic @CNemehMD @ThinkingCC #FOAMed #MedTwitter #MedEd

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Mourad H Senussi, MD, MS

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22 Sep 20

(1/)I've had several people ask me about details on how to use bedside ultrasound to confirm ET tube placement, detect esophageal and mainstem intubations, and adjust positioning.

So here is a step by step guide!

Ref: journals.lww.com/ccejournal/Ful…

(2/)**Overview** this protocol utilizes sequential tracheal and bilateral thoracic lung ultrasound.
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(3/)**Tracheal Ultrasound**
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Mourad H Senussi, MD, MS

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https://twitter.com/msenussiMD/status/1278480975643709440

(1/24)*De-mystifying Hepatic waveforms*
Welcome to Part 2. Now that we have gone through the basics:(

https://twitter.com/msenussiMD/status/1278480975643709440

). Time for a deep dive where we can start to decipher the important clinical information we need to apply at the bedside #showmethewaveforms #shocksquad

(2/24)We must acquaint ourselves with the different guises that HV waveforms may appear, they can be
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See⬇️

(3/24)The fun doesn't stop there! We all know how the atrium augments flow to the ventricle. With atrial relaxation (analogous to x-descent on JVP) that downward deflection helps increase forward flow during systole. With TV closure, you can see a notched S-wave (S1, S2).

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Mourad H Senussi, MD, MS

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(1/ )There has been an overwhelming interest in the use of hepatic waveforms as a congestive parameter. With social media, somewhat obscure concepts like these are quickly brought to the forefront and implemented in clinical practice. Many are eager to incorporate #VEXUS but...

...a thorough understanding of these waveforms, hemodynamic correlates, and dynamic changes that occur in physiology and disease, is paramount to incorporating this into practice. #shocksquad #tweetorial #VEXUS #showmethewaveform. Here are rules of interpreting hepatic waveforms

(2/13)Rule 1: **Nomenclature, nomenclature, nomenclature! **
That’s right! For us to understand each other we must speak the same language. I have heard these waves being described in a multitude of ways which has brought about considerable confusion and miscommunication.

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Mourad H Senussi, MD, MS

@msenussiMD

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