VEXUS Lite: Screening for Venous Congestion with Handheld POCUS. #FOAMed, #FOAMus

So recently a colleague asked me about one of my twitter posts where I had put a clip of doing venous congestion assessment using a handheld – which is without pulsed Doppler (PW).¬† Since VEXUS is predominantly based on Doppler findings, seems like 2D and colour might not cut it, but can it be done in a screening or “lite” fashion?

Definitely. Here is a mini-discussion about it, and some clips below to illustrate.

 

Pulsatile PV

Clearly Pulsatile PV likely near 100%

Ascites, plethoric IVC, pulsatile PV, markedly abnormal HV with “police siren” appearance due to substantial retrograde flow – likely VExUS 3 or C.

Normal looking HV

Markedly abnormal HV

 

Love to hear some questions or comments!

 

of course, lots of VExUS discussions with William Beaubien Souligny, Andre Denault, Rory Spiegel, Korbin Haycock and myself at H&R2020!

cheers

 

Philippe

 

The Resus Tracks: Medical Arrest REBOA with Zack Shinar! #FOAMed, #FOAMcc

So I’ve had the pleasure of knowing Zack for a few years now, ever since he and Joe Bellezzo (the EDECMO Team – along with Scott Weingart) came up to Montreal to teach at CCUS 2013 where they first told us about ECPR. I was instantly hooked, and after the CHEER Study came out in 2014, have been on the path to get this going in my shop, Santa Cabrini Hospital in Montreal, Canada. A tall order for a Canadian community hospital, but hey, I’m in the business of saving lives, and always felt and will feel that any patient crossing thru into a hospital I work in should get the best care that my team and I can possibly put together.

I think any invasive procedure is within the reach of any dedicated resuscitationist with reasonable procedural experience, with the proper training, and inserting ECMO cannulae, and Joe and Zack, a couple of awesome ED docs, showed this clearly. Its use is now spreading, and though there are – as always – many pundits, there is little question that this technique can save lives – the key being selection and subsequent management.

So here Zack tells me of another potential use for a tool I really like. We have recently acquired this technology and I’m looking forward to using it. REBOA is a tool used to control bleeding – a non-surgical cross-clamping of the aorta. But here, we explore how it might be used in another, more common setting… and I love the physiology of it!

Here you go – and apologize if it may be a bit choppy as we had connectivity issues, but I think Zack’s message comes out nonetheless!

 

This is what a REBOA looks like:

You can see how aortic occlusion beyond the takeoff of the left subclavian will concentrate CPR-generated blood flow to coronaries, cerebral circulation and arms, none being “lost” to the viscera and lower extremities. This makes ROSC more likely by improving coronary perfusion pressure and may improve neurological outcome by improving cerebral perfusion pressure.

 

Oh yeah, and anyone who enjoyed this, going beyond the cutting edge, don’t miss H&R2020, whose ethos is just that. Physiology and going beyond the cutting edge. A REBOA workshop will be part of the Resus Toolbox – one of the pre-conf courses!

cheers

 

Philippe

The Santa Cabrini Hospital ICU Trainees’ Guide

 

 

A GUIDE FOR RESIDENTS & STUDENTS

Welcome to the Santa Cabrini ICU Team.

This is a rather unique rotation for medical students and residents seeking to gain experience in critical care. Our 10 bed mixed medical-surgical ICU and 3 bed coronary care / step-down unit as well as critical care & procedural outreach structure will provide an array of opportunities to learn about critical illness as well as how to perform a number of critical care procedures, and particularly the chance to pick up or delve deeper into point-of-care ultrasound (POCUS).

The ICU staff are also seasoned educators and lecturers, at the national and even international level, and also involved in #FOAMed. Each will bring a particular dimension to critical care along the lines of their niches of expertise and interest.

 

A. BEDSIDE ULTRASOUND

The notable strength of the critical care team at Santa Cabrini is point-of-care ultrasound, and the expectation is that you leave with the ability to do basic bedside sonography following a 4 week rotation. With several ICU staff being high level bedside sonographers and educators, you can expect much of clinical management integrating live physiology. Although everyone’s practice varies, this is not a place where one-size-fits-all recipe medicine is applied, hence a heavy emphasis on physiology is to be expected, hence a topic to focus on while preparing for your rotation. You may also be exposed to resuscitative TEE (Trans-Esophageal Echocardiography) if cases present themselves.

 

B. PROCEDURES

The advantage of a busy community hospital is the relative lack of specialty territoriality combined with the requirements of patients with high acuity illness. Hence the critical care team has an extensive experience in all bedside procedures, obviously central lines, arterial lines, dialysis lines, intubation, chest tubes, lumbar puncture, thora- and paracentesis but also pigtail catheter insertion, percutaneous tracheostomy, percutaneous cholecystostomy and pericardial drainage. Because there is a maximum of two residents at any one time, you can expect to have done several of the basic procedures and to have been exposed to some of the more advanced ones.

Exposure to procedural skills is extensive due also to the procedural outreach team that takes care of the vast majority of invasive procedures done at our hospital. You will be responsible for following up the patients you performed or assisted in these procedures and thus learn the troubleshooting of the various devices, particularly pigtail drainage. It will be important to review the procedure here.

 

C. ACADEMIC RESPONSIBILITIES & RESEARCH OPPORTUNITIES

Each student or resident will be responsible for one presentation to the multidisciplinary team (physicians, nurses and others). You can discuss this with your attendings in the first week and decide upon a topic or article.

If an interesting enough case worth publishing presents itself, you are encouraged to write it up as a case report with your attending’s help.

For those interested in research, there are several ongoing or planned projects which you can take part of, particularly in the fields of resuscitation and point-of-care ultrasound. These can be continued in a longitudinal fashion after your rotation is over. Please contact Dr. Rola or Dr. Ajmo for further information.

 

D. SCHEDULE

For students and R1s there is no call. You may request to be called if there is an interesting evening or night case. R2s are expected to do 1 weekend (usually the 3rd or 4th of the rotation). There are no set hours and you are generally expected to arrive between 8 and 9 am depending on the attendings.

There are two attendings, one (“A”) taking care of the main ICU, and the other (“B”) rounding on the Coronary/Intermediate Care Unit as well as doing ICU consults and procedures in the hospital. You will be working with both, with the priority being to round on the ICU patients first, unless there is a new consult for admission to the ICU. You will also be responsible for the follow-up of the patients on which you have done a procedure outside of the ICU.

 

SUGGESTED READING AND RESOURCES (check for updates as this is a list in construction & evolution!)

Naturally, learning in medicine is a life-long journey. Several of these resources are exhaustive and longitudinal, and are meant to be companions on this journey rather than a quick brush up. Some are landmark articles or key chapters.

Articles:

 

Blogs & Podcasts:

Physiology: Dr. Jon-Emile Kenny has an amazing physiology site with unique diagrams, explanations and insights. http://www.heart-lung.org

The Internet Book of Critical Care: Drs Adam Thomas and Josh Farkas are creating the most up to date online textbook of critical care. A must.

The EMCrit Project. With Dr. Scott Weingart at the helm, this has become a core element in the #FOAMed world and contains a wealth of information on a number of ED and critical care topics. We encourage you to browse and follow.

Life in the Fast Lane – one of the pioneering #FOAMed sites, extensive resource. http://www.litfl.com

Dr. Ian Ajmo’s own FrancoFoam site is new and growing with some great podcasts on critical care in french (www.francofoam.com).

 

 

 

Thank you!

 

The Santa Cabrini Critical Care Team

Dr. Marco Charneux

Dr. Philippe St-Arnaud

Dr. Ian Ajmo

Dr. Daniel Kaud

Dr. Philippe Rola