A patient presents in shock:

BP is 100/35

A wide pulse pressure (low diastolic) is suggestive of a distributive shock

With an important exception

👇

1/

#FOAMcc #foamed #MedTwitter A narrow pulse pressure ~ BP 80/60 makes me think low cardiac output and high SVR

Simplistically, the stroke volume is low so a high systolic pressure is not generated

Compensation = increase SVR and a higher diastolic pressure

Causes cardiogenic shock, hypovolemia, etc.

2/

Can epinephrine cause hypotension?

A patient is transferred the ICU with hypotension on 4 mcg/min (.05 mcg/kg/min) epinephrine. Thought to be a GI bleed, resuscitated but was still hypotensive with a HR in the 60s, BP100/40 (60)

Takes carvedilol

Epi stopped MAP 60->90 🤯

How It is related to the dose dependent effects of epinephrine

At lower doses (<.1 mcg/kg/min) it has more beta 1 and beta 2 activity than alpha 1 (vasoconstriction)

Beta 1 increases inotropy (⬆️ stroke volume) and chronotropy (⬆️ HR)

Beta 2 reduces vascular tone (vasodilates)

🧪Can you have a metabolic acidosis with a normal plasma bicarbonate?

Lessons learned from a case

👇

#FOAMed #foamcc

1/ A patient presents ill after being found down and altered

Sepsis from a pneumonia is suspected

Labs:
Na 130 K 5.0 Cl 75 Bicarb 25
Cr 3.8 BUN 120 (Acute renal failure)
Glucose 520 (h/o type 2 DM)
Lactate 3
Ca 13.0
pH 7.41 pCO2 45

2/

Important lessons 📜 from ICU case:

🚨Not everything is septic shock
🚨A limited echo has limitations

Older patient in shock on 3 vasopressors, who initially presented with dyspnea and a CXR like 👇

What the diagnosis?

#FOAMed #FOAMcc

Image credit: ahajournals.org/doi/10.1161/CI… Presented to the ED with acute onset dyspnea, new O2 requirement 6 L NC, minimal PMH

BP 95/70, HR ~ 100, afebrile

Hypoxemia worsened during ED stay requiring intubation

Now hypotensive

CT obtained with unilateral right sided pulm infiltrates, small pleural effusions, no PE

New heart failure presentation and a BP like this 114/33?

👇

😯🚨

#FOAMed #FOAMcc We often see a large pulse pressure in distributive shock (sepsis) from a low SVR (vasodilation)

Not everything is sepsis, don't be fooled! 🧐

When seen with an acute heart failure presentation 🫀🫁 it may be acute aortic valve regurgitation

Endocarditis is a common cause

Can you be in shock and HYPERtensive?

I think so. Our patients teach us many lessons

#FOAMed
#FOAMcc
@UVMEmergencyMed

👇 A patient presents with 7 days of dyspnea, LE edema and fatigue. They have run out of all meds 2 weeks ago #COVID. They had an MI with ishcemic cardiomyopathy EF ~30%, also has a-fib.

Massive variceal bleed and no EGD at your hospital?

Be ready to place a blakemore/balloon tamponade device in uncontrolled variceal hemorrhage.

Tips from prior cases

#foamcc
#foammed After ABC's...

1. Place the device like an OG

2. Check position by xray (may need little air ~50 ml in balloon to see)

3. Inflate gastric balloon with ~ 250 mL air

4. X ray

Don't over inflate

👇

Image: overinflated and improperly positioned causing gastric distension 😯

Tips on the mechanically ventilated ARDS and sick hypoxemic patient.

Protect the lungs from the start! See the basics below.

#Tweetorial #foamcc #foamed

Based on prior work with @mattroginski @roo_atchinson

@UVM_EM

1/ What is the definition of ARDS?

The Berlin criteria: Acute onset within one-week, bilateral opacities on CXR not explained by cardiogenic pulmonary edema, pleural effusion etc. and a PaO2/FiO2 ratio of <300 mm Hg with PEEP 5 cm H2O.

jamanetwork.com/journals/jama/…

2/

You intubated the asthmatic! What to look for on the vent and what to do about it.

It gets complicated, but the basics are in the thread below

#foamcc #foamed #tweetorial mini
1/ The problem is bronchospasm and secretions narrow the airways and lead to obstruction, limitations in exhalation and high airway resistance.

On the vent, this is seen as a high peak pressure (high resistance) and a prolonged expiratory flow or incomplete exhalation.
2/