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May 29 10 tweets 10 min read Twitter logo Read on Twitter
ICU pictorials: A patient was admitted for "weakness". Unimpressive vitals / phys exam / labs. A few days later because of temp 101 F, a fever w/u was initiated. Due to "SOB", a CT chest angio was done:
👆Massive saddle PE extending in both sides w evidence of R heart strain ImageImageImage
Echo findings:
There was a clot in transit in the RA / RV. If you notice, the saddle PE was visible at the PA bifurcation: Image
If you had to guess the combination of BP and O2 sat on room air, at the time of the CT, what would you choose?
Patient had BP 120/86 and O2 sat was 94% on room air Image
Take-home message:
A patient can have huge PE clot burden WITHOUT hypotension or hypoxemia. Ruling out PE on the basis of "normal O2 sat and BP" can have dire consequences...
I hope the requests for CT chest angio will not exponentially increase after this post...

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More from @IM_Crit_

May 27
ICU Quizzes:

What is the most common electrolyte abnormality seen in the hospital?
👆 C.

In what time frame of development, is a hyponatremic episode considered acute?
👆 C.

If the onset of hyponatremia is unknown, it should be managed as:
Read 5 tweets
May 26
I was checking again today about DKA/HHS in a very modern & easy to read textbook and I saw this about the Na correction: Image
The Katz correction factor is 1.6 mEq/L for every 100 mg/dL that the serum Glu exceeds 100 mg/dL & the Hillier correction factor is 2.4 mEq/L…
It seems that the textbook 👆 uses a sodium correction factor of < 1.0 mEq/L for every 100 mg/dL of Glu above 100 or applies the correction starting from a higher Glu level (probably 200 mg/dL?)
Read 9 tweets
May 25
ICU stories (last night): A patient had been admitted w pneumonia / intubated / on norepi 0.12. At 01:00 am, the nurse notifies you that urine output is 5-10 cc/hr for the previous 3 hours. BP is 99/44, HR 90, CRT 3 sec. You take the US in patient's room to see what's happening.
What POCUS finding(s) is/are likely to explain the oligo-anuria in the shortest amount of time?
If you (and the patient) are lucky, you may find this:
Read 8 tweets
May 12
ICU stories: Pt w "severe COPD" (ex-smoker; FEV1 30%) / chronic hypoxic-hypercapnic resp failure on 2-4 l/m O2 @ home / diastolic HF / HTN / HLD was brought to the ED due to "altered mental status" & "shortness of breath". S/he left the hospital 3-4 months ago after an episode
of "COPD exacerbation" (the 4th during the last 12 months). In the ED: sat in low 80s & after a brief non-rebreather mask trial, pt was placed on NIV. ABGs: PCO2>100 (above detection limit), pH 7.14, HCO3 undetectable. Pt suffered 2 grand mal seizures, & after receiving
lorazepam & 2l NS, s/he was intubated (roc+keta) & rushed to the ICU. Per ED: ECG w sinus tach & CXR "COPD lungs" & R basilar infiltrate. Labs: WBC 14K, creat 2.0 (baseline 1.4). You examine the pt quickly: sedated-?paralyzed/decr BS & wheezing bil/trace ext edema/skin not cold
Read 23 tweets
Apr 28
ICU stories (a brief one): A 40+ yo pt w hx of bipolar disorder/asthma/GERD/HTN was brought to the ED by EMS after his wife found him lethargic ("altered mental status"). Apparently, he had spent the previous 2 days isolated in his forest cabin. Upon ED arrival, he was obtunded
& was given Narcan with no improvement. Vitals: 140/90, hr 80, rr 22, afebrile, sat 97% on room air. He could respond to simple questions. CT brain was negative. Lab work/up showed Hct of 59%, wbc 11k, PLT 400k and a chemistry panel showed: Image
A urine drug screen was sent 👇 while patient admitted that he had probably taken more Xanax (alprazolam) pills than he should. However, he denied that he wanted to hurt himself. Image
Read 18 tweets
Apr 27
ICU Reminders:

RV-predominant cardiogenic shock

RV failure criteria: Image
RV pressure-volume loops: Image
Etiologies of RV failure: Image
Read 6 tweets

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