1/ #tweetorial

💠 Beyond Diuresis – Treatment Adjuncts in Cardiogenic Pulmonary Edema.

➡️ Diuretics have traditionally been a mainstay of therapy for cardiogenic pulmonary edema.

manualofmedicine.com/topics/cardiol…

#meded #foamed #medtwitter #cardiotwitter #cardioed
2/

➡️ Diuretics may not be the preferred initial therapy for those patients with vascular failure, who are often euvolemic, or those with cardiogenic shock, who are often hypovolemic.
3/

➡️ In these patients, the emergency provider should first optimize preload and afterload reduction with the use of noninvasive positive pressure ventilation (NPPV), nitrates, or inotropes as indicated.
4/

➡️ Early use of NPPV significantly reduces rates of intubation and inhospital mortality.

➡️ NPPV decreases preload and afterload by increasing intrathoracic pressure.
5/

➡️ Nitrates should be administered early and rapidly to maximize preload and afterload reduction.

➡️ At low doses, nitrates dilate the venous system and reduce preload.

➡️ At higher doses, nitrates produce arterial dilation with resultant afterload reduction.
6/

➡️ Sodium nitroprusside is an alternative that may be useful in patient’s refractory to nitroglycerin therapy

➡️ For patients presenting with pulmonary edema secondary to cardiogenic shock, an inotrope such as dobutamine should be initiated to improve cardiac output.
7/

➡️ Recent data suggest worse outcomes with the use of morphine for cardiogenic pulmonary edema.

➡️ Diuretic administration should follow the use of more rapidly acting preload and afterload reducing therapies, particularly if there is little suspicion of volume overload.

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More from @ManualOMedicine

Jan 11
1/ #tweetorial

💠 Caustic Ingestions - Key Points

➡️ Serious ingestions can immediately result in perforation, shock, and even death.

➡️ Caustic materials cause tissue injury by chemical reaction.

- Read More : manualofmedicine.com/topics/emergen…

#meded #foamed #medtwitter
2/

➡️ Acids cause coagulative necrosis, which results in a self-limiting burn pattern

➡️ Alkaline materials induce liquefactive necrosis with diffusion into deeper layers of the injured mucosa. Even low concentrations of alkaline ingestion can cause extensive injury.
3/

➡️ Caustic Ingestion can provoke injury from the mouth, the airway, down through the esophagus to the small intestine.

➡️ Long-term complications can lead to strictures and an increased risk of esophageal cancer.
Read 9 tweets
Dec 30, 2021
1/ #tweetorial

💠 Boerhaave Syndrome - Key Points

➡️ Boerhaave syndrome is a spontaneous rupture of the esophagus from barotrauma related to retching or any sudden increase in intraabdominal pressure against a closed glottis.

manualofmedicine.com/topics/gastroe…

#medtwitter #foamed #meded
2/

➡️ Classically, we associate Boerhaave syndrome with Mackler triad:

👉 retrosternal chest pain
👉 vomiting
👉 subcutaneous emphysema
3/

➡️ Boerhaave syndrome should be suspected in any patient who presents with retrosternal chest pain, neck pain, or epigastric pain, especially if it began after an episode of severe retching or bearing down against a closed glottis (weight lifting, defecation, childbirth, etc)
Read 8 tweets
Dec 20, 2021
1/ #tweetorial

💠 Anticipate Bleeding and Reverse Coagulopathies in Liver Failure - Key Points

➡️ Blood clotting in the setting of chronic liver disease is complex and may result in a net prothrombotic or antithrombotic state.

manualofmedicine.com/topics/gastroe…

#foamed #medtwitter
2/

➡️ Favoring bleeding (antithrombotic state) are:

👉 reductions in hepatically produced procoagulant factors (II, VII, IX, and X) and fibrinogen.

👉 thrombocytopenia due to reduced thrombopoietin production, splenic sequestration, and production of antiplatelet antibodies.
3/

➡️ Favoring thromboses (prothrombotic state) are:

👉 reductions in a strong anticoagulant factor (protein C).

👉 increased platelet activation due to elevated von Willebrand factor levels.
Read 10 tweets
Dec 6, 2021
1/ #tweetorial

💠 When an Appendicitis Doesn’t Follow the Rules

➡️ Acute appendicitis is the most common abdominal emergency.

-- Read More: manualofmedicine.com/topics/gastroe…

#medtwitter #meded #foamed
2/

➡️ It occurs when there is obstruction of the appendiceal lumen, from a:

👉 fecalith
👉 tumor
👉 infection
👉 hyperplasia of lymphoid follicles
3/

➡️ Classic symptoms include pain that is initially vague and periumbilical followed by a more localized parietal pain in the right lower quadrant.

➡️ Only 50% of people present with these classic symptoms; in the other 50%, appendicitis can be difficult to diagnosis.
Read 10 tweets
Nov 25, 2021
1/ #tweetorial

💠 Pearls in Syncope ECG Interpretation.

➡️ In the patient with syncope, the ECG should be scrutinized for signs of Ischemia, Bradydysrhythmias, Tachydysrhythmias, and Conduction delays.

--Read More:
manualofmedicine.com/topics/cardiol…

#meded #foamed #medtwitter #cardioed
2/

➡️ Additional critical diagnoses to consider that can be detected with ECG:

👉Ventricular Preexcitation (WPW)
👉Brugada syndrome
👉Long or short QT syndromes
👉Hypertrophic Cardiomyopathy
👉Arrhythmogenic right ventricular dysplasia
👉Catecholaminergic polymorphic VT
3/

➡️ Ventricular Preexcitation (WPW)

👉 PR segment < 120 ms
👉 QRS complex > 110 ms
👉 Slurred upstroke of the initial part of the R wave (delta wave)
➖ Type A: delta wave in all precordial leads, R > S in lead V1
➖ Type B: negative delta waves in leads V1 and V2
Read 10 tweets
Nov 11, 2021
1/ #tweetorial

💠 Aggresive Nitroglycerin Usage in Acute Decompensated Heart Failure (ADHF)

➡️ Diuretics should not be considered first-line therapy in the ED treatment of patients with ADHF.

manualofmedicine.com/topics/cardiol…

#medtwitter #meded #foamed #cardioed #CardioTwitter
2/

➡️ The majority of ED patients who present with ADHF are not volume overloaded. Rather, their pulmonary congestion is due to volume redistribution.

➡️ High-dose nitroglycerin therapy should be initiated early in ADHF, especially in patients who are hypertensive.
3/

➡️ Often, these patients arrive to the ED by ambulance and receive sublingual nitroglycerin therapy (0.4 mg every 5 minutes) during their transport.

➡️ Do not begin a nitroglycerin infusion at a dose less than that provided by the sublingual route.
Read 6 tweets

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