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@IM_Crit_

Jan 15

https://twitter.com/IM_Crit_/status/1614457555568234501

Judging from yesterday's post, many friends are interested in how to get the most out of these books 👇 and ace the exams, so a few more tips are on their way:

https://twitter.com/IM_Crit_/status/1614457555568234501

1. Tylenol use can lead to high anion gap metabolic acidosis. Don’t ask me about the mechanism!
2. Every patient who manages to fly eastbound with Southwest Airlines & subsequently develops pneumonia not responding to common antibiotics has actually blastomycosis

3. Every oncology patient who receives chemo is destined to develop tumor lysis syndrome. Please learn about hydration/allopurinol/rasburicase
4. Along these lines, every oncology patient on immunotherapy will develop pneumonitis. Remember the steroids from yesterday’s post?

Read 8 tweets

IMCrit

@IM_Crit_

Jan 15

@accpchest

These books from @accpchest & @SCCM represent my study goal for this month. Before starting any (re-)certification exam & especially f you want to ace the tests, there are a few recent trends (& old habits/tricks) that you need to be aware of:

1. If there is an option of "doing nothing", this is most likely the correct answer.
2. There is always a mixed metabolic disorder. Memorize Winter's formula.
3. Prepare for several COVID-19-related questions. No surprise here...

4. TEG is very popular. Even of you are a dinosaur, you have to learn the basics about visco-elastic tests.
5. I know you have no CAR T-cell therapies in your hospital (& no one can really spell them correctly), but be prepared for managing cytokine release syndrome.

Read 9 tweets

IMCrit

@IM_Crit_

Jan 13

ICU stories: 65 yo pt, fairly healthy besides HTN & an episode of diverticulitis 3 y ago, is brought to the ED due to 2 wks' hx of abd pain & 1 d hx of N/V ("coffee-ground"). Looked "bad". SBP in 60s - improved to 80s w ivf. Intubated. Had CT A/P 👇:

While you review the CT images, you get the lab results: Lactate 10, WBC 3K, INR 2.0, BUN/Creat 100/3.0, CRP 500 mg/l, Procalcitonin 300. The ED is calling you for the admission. What consult(s) do you ask?

The CT A/P showed a large amount of free intra-peritoneal air; stomach & SB were mildly distended & partially fluid-filled. There was colonic diverticulosis without diverticulitis & mild wall thickening involving the descending colon & the sigmoid colon

Read 13 tweets

IMCrit

@IM_Crit_

Jan 12

ICU stories: 70 yo pt without medical hx but tobacco use (2 ppd x 40 y) was admitted w shortness of breath a wk ago. CXR/chest CT without PE/infiltrate. Was in afib/RVR on admission; placed on heparin & dilt/b-blocker (w some hypotension). Remained dyspneic, at times restless,

“requiring” multiple sedatives, & eventually was brought to the ICU. Intubated for "resp distress" & mental status changes. "Formal" echo, the day of ICU transfer, showed “LVEF 20% w global LV dysfunction”. On the vent 50% - peep 10. BP 110-130/60-70. Lactate < 2.0

Cards follow for "well compensated heart failure". A look w POCUS upon ICU admission:

Read 20 tweets

IMCrit

@IM_Crit_

Dec 26, 2022

How do you examine the lower extremity venous system when you look for deep vein thrombosis? What points do you check with the probe? Do you use Doppler? What are the recommended protocols? The Society of Radiologists in Ultrasound recommends a complete duplex ultrasound:

👆 The black rectangles represent the extent of the compression US. The gray rectangles are the sites of Doppler.
2-CUS (2-points compression US) includes compression of the femoral veins 1-2 cm above & below the saphenofemoral junction & the popliteal veins
up to the calf veins

ECUS (extended compression US), includes compression US from the common femoral vein through the popliteal vein up to the calf veins confluence

CCUS (complete compression US), includes compression US from the common femoral vein to the ankle

Read 9 tweets

IMCrit

@IM_Crit_

Dec 23, 2022

Following up on a discussion during ICU rounds this am: Like most laboratory values in medicine, pH and lactate levels should be evaluated in their context. In this 👇 old study of 6 male oarsmen who participated in a maximal effort on a rowing ergometer,

the two lowest pH values were 6.74 and 6.76 (corresponding to [H+] of > 180 nmol/L); the HCO3 levels were undetectable. The lowest lactate level was 32 mmol/l. The oarsmen remained conscious and did not require medical help

The conclusion of the study was that "in healthy humans, pronounced, but transient,acidosis is well-tolerated". Finding a pH of 7.05 or a lactate of 10 is usually not a big deal in a patient with DKA or (post-)seizures

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