#POCUS for post-renal AKI: a basic approach and a review of key images.

Overview here, more details in thread.
1/ Sample case: 60s m with HTN, DM2, presents with fatigue, Cr 6.0 from b/l 0.5. No flank pain or fever. UA no blood, protein, WBCs, LE, nit. No nephrotoxic meds. Empiric 2 L IVF given. Foley placed - some blood, 10 cc UOP over 8 hours. Renal USG ordered. Nephrology consulted.
2/

Classic conundrum... PNA vs cardiogenic pulmonary edema

60 y/o no PMH presents with dyspnea, hypoxemia. SpO2 92% 6L NC HR 120 RR 30 BP 110/70. B/l crackles. No JVP or LE edema. Lactate 4.0. BNP 3x ULN (nco baseline). Tn 2xULN Procal 0.2. Pre-COVID.

How can we apply #POCUS
1/ For the sake of argument, let's assume for this case
1) pre-test probability of PNA is 50%
2) pre-test probability of cardiogenic pulmonary edema is 50%
3) one or both of the above must be present to explain the presentation
2/

Humbling pleural procedure case to share.

70 y/o admitted with fever, hypoxia, R flank pain, loculated pleural effusion (right lower) on CXR. Concern for empyema prompting abx, chest US and possible intervention.

How would you manage? (poll to follow)

#POCUS #IMPOCUS

1/ 2/

A tweetorial on optimal machine settings for B line image acquisition, with a focus on: focal position at pleura, harmonics off, and increased far gain.

Inspired/based on the recent article - onlinelibrary.wiley.com/doi/full/10.10…
@cameron_baston @IsaacMatthiasM1

#POCUS #IMPOCUS

1/18 Let's start with some polls
We will stick to low frequency probes here (i.e. curvilinear and phased array - linear has its own purpose for detailed pleural assessment)

Which preset do you prefer for B line assessment?

2/

1/
Thread: Ultrasound for CVC placement - more than just follow the needle tip and confirm the wire.

There are many potential uses of ultrasound during CVC placement, shown here. Not all are essential.

#POCUS #IMPOCUS #FOAMED #FOAMUS 2/
Pre-procedure
Lung sliding on ipsilateral side - for a comparison to post-procedure
-use linear probe
-apical and lateral/anterior

Let's talk about placement of small bore nasoenteric feeding tubes and use of ultrasound for this (A thread)

Scenario: Pt with gastroparesis and COVID/ARDS, planning to prone, want post-pyloric tube. No dedicated team for this. Can we place safely w #POCUS guidance?

1/ How is small bore feeding tube (SBFT) different from standard NG?

Narrower (6-8 Fr vs 14-18 Fr), more flexible (but w rigid stylet for placement), longer. Thus: more comfortable, gastric or post-pyloric, ineffective for suction, prone to clogging, prone to PTX if placed in lung.

1/
Happy Monday everyone! We have a special case for you today written by UPMC PGY2 #POCUS enthusiast @MikeTao15.

A 52 yo M with hx of EtOH/HCV cirrhosis, VTE on Eliquis, HFrEF presents w worsening abd distention and pain. He is disoriented and unable to give much history. 2/
Cirrhosis previously complicated by esophageal varices, hepatic encephalopathy, and ascites. No follow up since last hospital admission at outside facility ~1 year ago. Has not been taking meds.

Vitals in the ED: Temp 38.1, HR 90, BP 98/70, Pulse Ox 96% on 2L

Ever found DVT POCUS challenging? We do.

Here is a #Tweetorial on #POCUS for Lower Extremity DVT assessment. Let’s walk through a case and discuss common questions that arise.

50s f no PMH presenting to the ED on a Friday evening with right leg swelling and redness...

1/ History/exam/labs:

No travel, surgeries, immobilization. No dyspnea, CP. No meds. No FH of VTE. no tobacco.

HR 88 SpO2 98% RA BP 160/90 T 37.

Exam unremarkable other than 2+ LE edema erythema and tenderness from right ankle to knee.

CBC/BMP/coags normal

2/

1/
After a break for the new year, we are back with a case of #POCUS and abdominal distension.

59 y/o m with no medical history presenting with increasing abdominal girth and now altered mental status.

#IMPOCUS 2/
HPI:
well until 3 months ago. Since then, progressive fatigue, nausea, mild diffuse itching without rash. Few weeks of early satiety, poor PO intake, and now increasing abdominal girth. Last BM 3 days ago. No vomiting. Weight unchanged over 3 months. No fevers/chills.

A lines, B lines, Consolidation… the ABCs of Lung Ultrasound

But what do they really mean?

Here we attempt a #tweetorial presenting a way of thinking about common patterns seen on lung ultrasound.

See table here for a summary, and thread below for details

#POCUS

1/ We will start with a hypothetical case for illustration
65 y/o f w HFpEF, COPD admitted 4 days ago with acute pancreatitis (now resolved). You are prepping her for discharge but she is now short of breath/hypoxic requiring 4 L O2.

2/

IVC image acquisition #IMPOCUS #MedTweetorial.

These 2 IVC M-mode images were obtained from the same patient 10 seconds apart. How could they be so different?

1/ 60 m with hx of COPD, HFpEF, admitted w LLL PNA s/p abx and 1 L LR. HR 118 BP 110/70. IVC US was performed as a piece of info in determining whether to administer more IVF.

Measurement 1: 2.35-->0.92 (65% collapse)
Measurement 2: 2.22-->2.09 (5% collapse)

Why so different?

2/

Renal #IMPOCUS case here! Will start w case stem, more info and poll below, #POCUS images to come

65 m w hx of BPH, kidney stones, in ED w fevers/chills/N/V/back pain. Dx acute pyelo, possible stone

What is our approach to imaging, and mgmt plan? Role of POCUS in this case?

1/ More info

Prior dx of kidney stones on CT (6-8 mm, unknown type), managed medically. Has intermittent L flank pain. Last 2 days - f/c/n/v/back pain.

T 38.6 HR 98 BP 154/88 SpO2 99%
UA: 1+ blood, 3+ LE, WBC TNTC
+L CVA and suprapubic tenderness
WBC 18
Cr 1.6 (baseline 1.3)

2/

1/
#IMPOCUS and thoracentesis case here - with a particular focus on pleural physiology, for discussion/eduational purposes

We see the following X-ray...
See thread below for the story leading up to this. Let’s try to sort out what is going on and what to do next.

#FOAMUS 2/Tagging POCUS friends/recent participants @SonoInternist @DRsonosRD @jelevenson @ria_dancel @msenussiMD @trobertson8 @G2Disrupt @IM_POCUS @buckeye_sanjay @benjikmathews @POCUS_Society @kyliebaker888 @CaseMcQuade @MedEdPGH @HeyDrNik @tweebui @UltrasoundJelly @5MinSono @awfujita