Month: August 2014

August 27, 2014

Pericardiocentesis for tamponade w/bedside ultrasound: Procedure Video. #FOAMed, #FOAMcc, #FOAMus

So this case was interesting on a couple of levels.

A 76 year old woman presented to the ER with a complaint of abdominal discomfort and was admitted with a diagnosis of pneumonia and lower abdominal cellulitis. She had a history of diabetes, obesity and remote oral cancer which had been treated 6 yrs ago.  The next morning, while still in the ER awaiting a ward bed, she had a hypotensive episode, and fortunately the ER doc on shift grabbed an ultrasound probe and took a look, calling me a few minutes later with a diagnosis of tamponade. She was absolutely correct. I saw and echo’d her shortly after:

The first two clips show the IVC, which is distended with minimal variation. This should prompt the bedside sonographer to anticipate downstream pathology (except for iatrogenic volume overload and renal failure…).

The subsequent clips show subxiphoid views (and one clip of the associated left pleural effusion) showing a significant pericardial effusion and difficult to distinguish cardiac chambers.

Clinically, she was dyspneic, uncomfortable, HR 115, BP 130’s systolic (in ER in 80’s then got some fluid). Her heart sounds were not particularly quiet, and her JVP was difficult to assess due to obesity.

Here is the drainage video:

Her abdominal pain resolved very rapidly, her breathing improved and vitals stabilized.

Pathology is still pending, but bloody effusions commonly include malignancy, tuberculosis, but also simple viral paricarditis.

So I think this is a great case for the argument of integrating ultrasound into physical examination rather than as an ancillary test.  Because she didn’t present with a predominant hypotensive or respiratory component, the diagnosis wasn’t seriously entertaine, and obesity, body habitus and pleural effusion undoubtedly made physicians overlook the cardiomegaly. However, in my opinion and that of most bedside sonographers, abdominal pain warrants an abdominal us exam, and the distended IVC would have prompted at least a quick cardiac assessment, and the effusion would have been noted immediately.

In my CC/IM practice, hardly anyone escapes the probe, as cardiopulmonary and abdominal status is hardly ever irrelevant to me…

cheers!

 

Philippe

August 20, 2014

Revisiting our beliefs about Fluid Resuscitation: An N=1 Podcast. #FOAMed, #FOAMcc

So if you keep abreast of the fluid literature, you’ll note that more and more logical voices are bringing up very, very valid points against the powerful cultural backdrop of aggressive fluid resuscitation in various pathologies. Paul Marik’s recent publication, a great SMACC 2013 lecture by John Myburgh, not to mention several studies and analyses (VISEP, SOAP) illustrating consequences of overzealous fluid resuscitation. On the other side of the fence, you have the guidelines of various associations proclaiming loudly that fluids are “critically important” that there is a need to be “aggressive” and “generous.”  However, scratch a little beneath the surface and find…very little besides opinion and history. Zip. Nothing.

So my aim isn’t to make anyone stop giving fluids, but instead to treat fluids as any other therapy. Carefully given and assessed rather than in hyped-up frenzy.

I invite every physician reading or listening to, for a few minutes, put pre-concieved notions aside and approach the problem from a neutral and educated point of view, and come to your own conclusion, as unbiased as possible.

So here is my little podcast.

 

cheers

 

Philippe

 

ps just as I was uploading, checked my twitter and noted a great addition to the body of analysis by Josh Farkas, check it out:

http://www.pulmcrit.org/2014/08/the-myth-of-large-volume-resuscitation.html?m=1

August 11, 2014

Salt water drowning…not just an environmental accident! Annals of Intensive Care 2014. #FOAMed, #FOAMcc

I’ve had the pleasure of knowing Paul for a few years as he has lectured at CCUS Symposia several times, and he is one of the few people I know who combine expertise, experience and a willingness – no, a passion – to think outside the box, challenge dogma and push the envelope of acute care.

In this month’s issue of the Annals of Intensive Care, Paul put together a great synthesis on fluid resuscitation, both the type and the quantity. It isn’t necessarily the kind of paper that gives you a cookie-cutter recipe on what to do, but rather the kind of paper that I really, really like: one that gives you a proper lens through which to see an issue, and a way to re-examine your therapeutic decisions.

SaltWaterDrowning

Tying in the type of fluid to the glycocalyx, the author leads us down the path of physiological resuscitation, which is currently not being performed.  There is certainly much, much more to come on the topic in the next few years, and we have to be ready to possibly radically change our practice. For the better.

So I think this paper should be a cornerstone for any resuscitationist, whether or not you actually agree with everything Paul says.  If you don’t, then do come up with a rationale to justify what you like to do, and perhaps teach us all something along the way. Preferably, this rationale should be physiological, and possibly evidence-based, and should not include any of the following catch parses:

“well, it’s what everyone does,” “this is what we do at (prestigious) University…” “I’ve been doing this for 20 years,” “They call it normal saline for a reason you know (dismissive chuckle),” and “there’s no randomized trial…”  and on and on.  When I hear that, time to close the discussion.

Enjoy the article!

 

PS for awesome talks by amazing speakers (including Paul Marik!), don’t forget to register for CCUS 2015!!! For more info: http://wp.me/p1avUV-aU and register at http://www.ccusinstitute.org!

Philippe

 

 

 

August 5, 2014

Ultrasound for broken bones? Nix and Stone take over at CCUS 2014. #FOAMed, #FOAMus

Do you know how to use bedside US to find and freeze fractures?  Here, Catherine Nix and Mike Stone go over the nuts and bolts of it.  Cool stuff.

 

http://www.ccusinstitute.org/Video.asp?sVideo=CatherinNix

 

 

enjoy!

 

 

Philippe