#Ogitorial No35: hypothetical 41F #COVID19 intubated after failing NIV trial (24h).
A ETT 25cm
B SpO2 82% FiO2 1 Vt350 P12
❤️BP 110/80 HR 95, CapRef 1.5”
D avpU (propofol)
E Obese, no rash, soft abdomen
U bil B lines, RV=LV, EF~60%,
L pH 7.29, PCO2 35, Cr 1.4, Lactate 2.2 Hb10 Patient got remdesivir & dexamethasone. SpO2 88% after bolus NMB & pulling ETT(3cm). As you increase PEEP to 18, driving pressure improves, but the SpO2 drops to 72% without hypotension. You decrease PEEP back to previous but SpO2 still 70s. The next step is: #FOAMcc #MedTwitter

1/ Please use EXTREME caution with using human resource intensive strategies in patients with #ARDS from #COVID-19.
Very early intubation, very early prone position or early ECMO will expose staff to risk and are unlikiy to bring additional benefit to most patients. 2/ I have been treating and studying ARDS for 20 years and extremely simple approach is by far the most beneficial:
- Try high flow/NIV
- Intubate if above contraindicated/failing (not based on ABGs, no need for ABGs) AFTER informed consent and goals of care discussion

1/#Ogitorial No21 Real Patient with Consent. 42M, previously healthy collapses upon entering ED
A ok
B clear, bag/maskFiO2
♥️ BP 60/, HR80 Epi drip
D avPu
E punctate skin marks, diaphoresis, ashen skin, L eyelid swell
U - dark ages
L Hb10, WBC6,K 2, Na146, HCO3 12, Lact 2.4-4.5 You place (just in case) DC pads, replace K/Mg. ED volunteer says: prior to collapsing, the patient mumbled “bees”. You speed up fluid (5LNS/1h), add steroid & H1/H2 blocker with ⬆️BP but severe rigors, anxiety & delirium. The risk of future PTSD is best ⬇️ by:
#FOAMed #FOAMcc

1/ #Ogitorial No19: 49M with 2 day fever, cough & hemoptysis comes to ED at 3AM with respiratory distress & Afib RVR. History significant for HepC, smoking, methadone, warfarin post ablation. ED Rx: 2L LR, intubation (RSI), amio & phenyl bolus, ceftriaxone, azythro, steroid. 2/ Arrives to ICU at 6AM:
A ETT @ 24cm
B AC32,TV440, P9,O255%,Ppl 20
❤️HR 72 89/48, CVP7, CapRef1.5”
D avpU propofol @ 80
E unremarkable
U R>L B lines, normal LV/RV
L WBC 22, Plat 165, Cr 2.0, INR7.2, Hb11.2, ABG pH7.26, PaCO2 39, Lact 4.5

For technical reasons the presentation: “ARDS: Causes and Prevention” did not make it to @ats @ArdsGlobal webcast: thoracic.org/patients/lung-…
I thought the highlights below will be useful for patients and clinicians alike.
1/ What is #ARDS? 2/ What conditions predispose to #ARDS?

1/ #ClinicalResearch Primer
A personal hands-on experince:
You’re interested in causes of ARDS & transfusion comes up. Literature review=many ?s: Is it the reason for transfusion or transfusion itself? Is it just fluid? Is it RBC or plasma. Is it “storage lesion” or antibodies? 2/ You dig deeper and find some fascinating studies largely known only by transfusion specialists:
ncbi.nlm.nih.gov/pubmed/4071603
ncbi.nlm.nih.gov/pubmed/11960539
You get your feet wet in a retrospective cohort study using a standardized definition (for the first time) ncbi.nlm.nih.gov/pubmed/16965572