We are heartbroken to learn of the sudden passing of Dr. Rakesh (Rick) Patel. He served his residency here, had completed a fellowship in Infectious Diseases, and was currently training as a Critical Care fellow. Dr. Patel will be greatly missed.
I’ll save you the reading time :
Hypotensive:: too unstable for scope
Not hypotensive: outpatient scope
“Establish peripheral access, transfuse pRBCs, don’t call after 9pm”
JAMA Clinical Guidelines Synopsis summarizes the 2023
@AmCollegeGastro
guidelines on management of patients with acute lower gastrointestinal bleeding.
There is no such thing as maintenance fluids
There is no such thing as maintenance fluids
There is no such thing as maintenance fluids
There is no such thing as maintenance fluids
There is no such thing as maintenance fluids
can someone please explain to me what is so magical about ABGs? Patient short of breath , "wow we should check an ABG" whyyyyyyyyyyyyyyyyyyyyyyyyy
STOP. CHECKING. ABGs
Dear cardiologists,
Ejection fraction is NOT EQUAL to stroke volume.
I am assaulted with ef on a daily basis for patients whose SV is actually good
But I am not a cardiac intensivist so silly me 🥱🥱🥱🥱🥱
Me trying to convince GI to come in the middle of the night to scope the patient who is exsanguinating because this is the most “stable” we’re gonna get
Disclaimer:: I am not a surgeon, but did have to do an emergency cric on a patient with massive hematemesis, a soiled bloody airway, who was coding. I've played this out in my mind mentally so many time and made the decision to cut before I hit the door. MY practical experience:
Following case has been altered but is based on real events:
I was called to the patient’s bedside for episode of SVT and hypotension. Our patient was admitted recently with acute renal failure and cardiogenic shock.
🚨🚨🚨🚨another edition of
#fromthetrenches
🚨🚨🚨🚨
Recent case of mine —> clinical details altered for anonymity
59 year old male presents to ED with SOB. Family states was at home at fell in bathroom. Hx of HTN/DM. Unsure of meds or compliance to therapy. Arrival BP 79/42 😱😱
@PulmCrit
85 year old patient
“Patients only eating 25% meals”
“What’s the diet order?”
“Carb conscious low sodium”
“Please get the patient ice cream stat”
What exactly are we accomplishing with these strict diet orders in elderly frail patients besides torture
Pt found down in shock. Brought to ED and Intubated, worked way from a little Levo to a ton of Levo very quickly. Get to bedside, gotta figure out what’s going on. Find this little bugger—This is why echo ☝️
78 yr old bad sys HF (ef 20%, also RV dysfunction with baseline TAPSE 1.0) in shock also has pneumonia (clinically and microbiologically)
These are recs: “Please start gentle hydration as patient looks clinically dry and has sepsis”
Takes me 15seconds to KNOW he isn’t
You’re intubating a patient who has bad pneumonia and likely ARDS. The patient is on BIPAP and is being pre oxygenated with that. Sat is 94% despite 💯 % fio2. You position appropriately and do all steps for high first pass success.
You get a view but the tube FALLS ON THE FLOOR
@EricTopol
@imperialcollege
We really need to be careful with the “no evidence” statement. I’m old enough to remember when there was no evidence that : covid spread person to person, that steroids didn’t help, that toci didn’t help, that covid wasn’t airborne, that we were immune after 2 doses
10 abgs for the chronic hypercapnic patient who is obtunded and just needs the NIPPV optimized but do one LP for undifferentiated AMS and everyone loses their minds
“Dad, what’s 30cc/kg?”
“I don’t know son. We don’t blindly follow recommendations based on weak outdated non-physiologic evidence whose major citation is just the previous committees guidelines”
#hocuspocus
#perfusionpressure
This is an amazing thread on pneumonia. But please god don’t do a 7% saline neb for an induced sputum. Hypertonic nebs INDUCE bronchspasm, decrease fev1, and aren’t patient centered or evidence based
Sputum cultures - underdone. Make efforts to get them and get them early. Think induced sputum in the ED with 7% hypertonic saline.
Neg cultures have value. If no MRSA/PsA grow, they're not there.
Viral options and multiplex PCR ($$$) highlighted below.
#SHEASpring2024
6/
Another edition of
#fromthetrenches
(courtesy of
@IM_Crit_
) :
:details changed:
59year old male PMH severe pulm htn comes to the hospital with increasing sob, edema. Admitted, developed shock, and was diuresed but eventually needed CRRT for AKI and volume removal.
Tales from the
#trenches
The sepsis paradigm that’s preached as dogma is fundamentally flawed.
TLDR:
My personal biggest hits on the “oh shit-o-meter” with sepsis is:
1.Hypothermia🥶
2.Lactic+sepsis+”normal BP” (so called cryptic shock)
3.⬇️low white count
4.Bandemia 🩹
Dear pediatricians, ED ped docs, adult ED docs who are ready to care for pediatric patients, PICU docs, peds nurses, everything pediatrics related
Thank you.
From a dad
Time for Another
#FROMTHETRENCHES
. Recent case of mine. (Details altered for anonymity).
60 year old female with PMH of HTN comes to the ED with complaint of RLE pain. States that she had recent fall and her RLE is now swollen and very painful. Triage BP is 79/42!!!!
Dexmedetomidine does NOT treat behavioral disorders.
Dexmedetomidine does NOT treat behavioral disorders.
Dexmedetomidine does NOT treat behavioral disorders.
Dexmedetomidine does NOT treat behavioral disorders.
Dexmedetomidine does NOT treat behavioral disorders.
Tales from the
#trenches
:
Overwhelming sepsis, aki, younger patient with not much comorbids, maybe diabetes or liver dysfunction?
It’s group A strep with toxic shock til proven otherwise
Add anti toxin, get aggressive: steroids, IVIG
Lessons: “looking dry/wet” are non-sensical terms that I don’t accept as an assessment, all hemodynamic decisions in decompensated pulm htn should be based on some echocardiographic imaging data (pocus or formal echo), las art line variation does not equal hypovolemia
Maybe it’s because I’m older now but as the usual last person to talk with the patient I ask such basic questions. None are really medical. I like to ask
1. Why did you come to the hospital? — the art of the chief complaint is really lost
2. What do you do?
Our residency is experiencing a heart breaking loss with the unexpected death of PGY2 resident, Ainsley Pratt. An absolute paragon of patient advocacy, I was very lucky to work with her in the MICU and witness first hand what happens when the doc gives 120% everyday.
#RIP
We are heartbroken with the loss of our dear friend and beloved resident, Ainsley Pratt. We will remember her for her unwavering courage, vivacious energy and unbeatable wit. Our thoughts and prayers are with her family and friends.
I didn't match. Found my way into a transitional year then went to IM then chief resident now chief fellow about to graduate. important lesson learned--->
"a smooth sea never made a skilled sailor"
#conditionedforchaos
@FewWillHunt
#MATCH2023
@DanMunro
@nurse_jaqwellen
Dan, I’ll take an average salary of your wise choosing if you wipe away my medical school debt 370k and I only work 40 hours a week and I’m free of litigation for errors, we’ll chalk it up to spillage—deal?
Cardiac output is always the sacrificial lamb on the alter of making the rate 120 instead of 135 in acute medical illness and I will never understand it
Often missed point is that the LV ef could be very high (70%) but the LVOT VTI could be veryyyyyyy lowwwwwww (<10)
the uninitiated would give fluid b/c the LV hyperdynamic but the secret🥤is 160lasix
Throw EF in the 🗑️ during acute illness
@msiuba
Can we just take a time out and really appreciate what
@CritCareReviews
has done since being founded? Provide a newsletter with the most up to date evidence, guidelines, podcasts, and now hosting a meeting for many pivotal CC trials-all from a FOAM mindset. Inspiring for us all!
@NoobieMatt
Meanwhile I’m sitting here like damn he really went all out for this sim session.
Old attending surgeon said train them well cuz one day you’ll be the one looking up at them for help
Hope you’re feelin better !!
We’re in a different time in the pandemic, but I’ll never forget those midnight conversations in my own mind with Intuabted patients and myself when I see their phone on the table and just wonder what messages they’d either wake up to or messages of love that were never seen
Teaching points:
1. Echo first always
2. Valvular disasters are an important consideration in acute resp distress/shock
3. Need to dx early so can get patient to place with appropriate therapies if needed
It's finally here!
#CHEST2024
Looking forward to tweeting my way through conference and Boston for 3 days!!!!
Please drop in the comments if you are coming or holding a session!!
@accpchest
@journal_CHEST
In short, tamponade is a clinical diagnosis that requires rapid assessment and treatment. This patient underwent pericardiocentesis and shock was resolving
@nursekelsey
Some people on this feed may be surprised to find out you go without water quite often for 8-12 hours at a time. It’s called sleep and somehow, maybe magic, they still work. Keep fighting!
Friends, let’s be honest. None of us knows anything about inhalers.
If you prescribe inhalers(IM, EM, FM, Peds), you need to listen to this episode
Shout to the inhaler 🐐
@AmberMartirosov
for giving her perspective and expertise to guide this discussion
There are many inhaler devices available and selecting the right device for your patient can be overwhelming. Listen today on selecting the proper inhaler, how to ensure proper inhaler technique and hear about great resources for you and your patients
🔗
Kudos to the
@emcrit
team for the mantra of Scalpel-finger-bougie because thats what I thought in my mind the whole it.
These are obviously high risk, low frequency procedures but in all honestly, its not as complicated as you think.
@kidney_boy
I force my students and residents to leave early—why? They’ll have plenty of time for the masochism, sometimes it’s unavoidable. Stayed late plenty of times intubating patients, putting in lines, calling families, running codes. Can only do it so long before the dread comes
@drgregkelly
I prefer to have the mitigation measures in place until we’re really certain we can control the outbreaks cuz it just feels like we’re still at its mercy and can’t prevent any wave from happening. The next few months should be a barometer for that.
3/ Moving on to our good friend phosphorus…We can think of hypophosphatemia in 4 🪣s:
Decreased intake🍴
Renal losses 🫘
GI losses 💩
Transcellular shifts ↔️
Levaquin gets a bad rep and for good reason probably. But, can we just have a moment of appreciation for this med that treat pseudomonas, is oral, is bio available AND can treat your patients co-infectious partner, stenotrophomonas.
🫡 levofloxacin
📢📢Midweek vent rounds !📢📢
You’re called to see a patient on MV for resp failure. Unclear etiology, no PMH because patient avoided care until he came in dyspneic and hypoxic. Pt appears intermittently agitated on the vent, team requesting more sedation
to those asking why-->fluids should have an indication attached to them. Patients being NPO or not taking oral is not the best use for them. I would argue if a patient is NPO for a certain period of time-->nutrition, lyte repletion should be done via NG tube not 75ccD5 half nml
Friends, "Sepsis", whatever that means, is truly the great masquerader.
This seemingly easy diagnosis lulls you into a sense of calm: fluids, antibiotics, lactate.
All the while, your patient with tamponade dies
Please note this is why patients on tube feeds in the icu should be managed with rapid acting q4 or regular acting q6 along with whatever basal insulin is needed. Great work. Add this to your FASTHUGS BID tweetorial
@emily_fri
We are excited to welcome
@pulmtoilet
as our newest Associate Editor to
@PulmPEEPs
Dr. Ghionni is faculty at MedStar Baltimore and was a former Chief Fellow
@MedStarWHC
Welcome to the team 🙌
@jmugele
Hot take: I feel like you can exchange "COVID" with any upper respiratory complaint and you'd get the same answer if the patient went to an urgent care.
Sometimes the most aggressive choice is do aggressively reasses, aggressively be at the bedside, and aggressively do nothing as opposed to doing something for the sake of doing something. Sometimes no action is the best action. But ALWAYS BE AT THE BEDSIDE
#MedTwitter
@emily_fri
@EM_RESUS
Agree w/new pulm attending. I’d add that there could be effusion -> pleura looks thickened which makes me think trapped lung, prob long standing process since patient isn’t Intuabted and has compensated so all this is chronic
👉👉👉 my take on an often encountered and consulted entity— the Solitary Pulmonary Nodule—any one can start the work up before referring over to your friendly neighborhood pulmonologist!!!
Releasing soon—the multiple nodule infographic!
What happens is that someone usually starts IV fluids for this reason (NPO) and they are maintained for days and days and you wind up with fluid overload, edema, and congestion esp in the frail medical patients (among other issues). If you got a GUT, USE IT!
@msiuba
As the kids say, TLDR:
Every patient with asthma should be on
ICS at every level of control and during exacerbation.
Amazing episode and infographic !!!
1/ 🚨 NEW
#BeyondJournalClub
with
@NEJMGroup
: Asthma Management & the Mandala Trial 🫁
Rescue inhalers for adult pts w/ asthma should include an ICS + SABA/LABA*
*unless the pt is very well controlled
🎧:
🖥️:
What we should remember is “sepsis” by definition is not an oxygen DELIVERY issue; it’s an oxygen utilization issue —
Sure some patients could use fluid but remember that’s NOT the issue in sepsis
1. Get source control
2. Antibiotics early and the right ones
3. Do no harm
@eemoin
“Pt self extubated and is now on room air”
It’s amazing how much group are uncomfortable with diagnostic uncertainty like anything we do in medicine is infallible.
In residency, we had reverse case—>thought was uti—> AMS persisted—>turned out to be HSV encephalitis