1⃣ Speak to your PH specialists about RVSP role and utility in PH diagnosis and management. That is not its role for the intensivist.
2⃣ Acutely, RVSP can help determine if there is a chronic component to elevated PA pressures (>60 usually not acute!), but does not rule out acute on chronic, nor pseudonormalization in severe RV failure
3⃣ More importantly: in the ICU, when without a Swann-Ganz catheter, RVSP can *help* (like all ICU data, not unilaterally) guide decisions about hemodynamic management such as inotrope/pressor choice, mechanical circulatory support, fluid management, etc.
4⃣ Understand Bernoulli's equation and its modifications to know when it cannot be applied (laminar flow, massive/torrential TR, elevated proximal pressure)
5⃣ RAP can dramatically alter the RVSP calculation; accurate assessment is crucial. The 2.1cm/50% collapse criteria are for spontaneous breathing patients only! Can use CVP if available.
6⃣ Your best/most aligned TR jet can be in any of several views: RV inflow, PSAX-av level, A4C, even subcostal. Check them all. Keep the one with the best envelope and highest pressure. Doppler will only underestimate.
7⃣ To reiterate: Patients don't read textbooks. Application of critical care echo requires understanding the principles behind the numbers/echos to determine how to appropriately apply findings to a specific patient at a specific time.
📢 What would you add/correct/change?
• • •
Missing some Tweet in this thread? You can try to
force a refresh
2⃣ Optimize the PLAX for the LVOTd. Sometimes I find that too much "optimization" actually makes it harder. Just know your options and do what works with your patient.
3⃣ Understand Doppler physics. Specifically PWD for this one. Recognize how the angle of insonation AND the angle of flow relative to the probe, affects your measurements.
This window is attainable only via a transESOPHAGEAL echo (TEE).
Point-of-care TEE is used widely in SICUs worldwide, and MICUs outside the US. You can expect to see them increasingly in US MICUs over the next decade. (2/8)
By viewing the heart via the esophagus, windows are often much crisper than when fighting with rib shadows, edematous lungs, and often bandages/wounds (esp. in surgical patients) on the chest. (3/8)
Greatly enjoyed launching our @MGH_PCCM@HarvardPulm didactic critical care echo curriculum with LV Assessment - Beyond the Eyeball!
Assessing LV function isn't as simple as it sounds.
Take home messages for POCUS learners below ⤵️: #POCUS#Echofirst#Medtwitter#PCCMTwitter
👀The oft-invoked 'eyeball' method is a deceptive oversimplification. You can't suddenly accurately assess LV function just because you're told to!
You need to train your eye to look at other quantifiable measures of LF function - even if you won't actually measure them. 🧐
Sure - make your best guesstimate of EF. But also look at:
1⃣myocardial thickening
2⃣myocardial excursion
3⃣annular excursion/MAPSE
4⃣fractional shortening +/- fractional area change
5⃣EPSS
You don't have to actually measure these, but you can't 'see' them if you don't know them!
🚨 A case of bactrim-associated ARDS!
BUT its backstory is one of sadness, selflessness, intrigue, sleuthing, clinical acumen, multidisciplinary collaboration, and most importantly, collaboration with patients and families themselves, led by @JennaMillerKC et al. #Medtwitter
It's a tale and disease perhaps ultimately worthy of discussion in the medical historical annals of @AvrahamCooperMD@tony_breu@AdamRodmanMD.
But more importantly, worthy of widespread dissemination for broad awareness, rapid identification and management, and further research.
This harrowing, bone-chilling, terrifying, powerful account of a present day, ongoing, Holocaust while the United States participates in the Beijing Olympics eerily parallels its participation in Berlin's 1936. We must learn from our recent mistakes and act now.
This piece reads as play-by-play a reenactment of the stories I learned about my grandparents and friend's families in the Holocaust. Acceptance of a progressively more racist and genocidal state. "It's not that bad", "it can't get worse", "our whole life is here".
Conjured optimism about future improvement. Hushed tones about the present. Frequent disappearances. Sleeping in clothing anticipating a nighttime arrest, public humiliation, before being sent to a concentration camp.
Session 1: Systematic Approach to Interpreting CT Chest led by Dr. Suhail Raoof!
FOMO? See: Algorithmic Approach to the Interpretation of Diffuse Lung Disease on Chest CT Imaging in @journal_CHESTjournal.chestnet.org/article/S0012-…
@journal_CHEST ⭐️ The secondary pulmonary lobule is your friend in teasing apart the lung parenchyma and defining where a disease process, anatomically, is taking place
⭐️ Hard to make them out? Start at the periphery