A Primer on Pigtail insertion. #FOAMed, #FOAMcc

So I recorded this for our incoming residents to Santa Cabrini ICU, whom we expect to become well versed in this procedure by the end of their rotation with us. The difference between a smooth and simple insertion – best for both patient and operator, is in the little details.

Figured I might as well put it up on #FOAMed in case anyone else may benefit!

Here is the podcast:

 

And here is a video displaying the technique.

 

cheers

 

Philippe

 

 

L’Échographie au chevet pour l’Interniste: ASMIQ/CCUS 2014, #FOAMed, #FOAMcc, #FOAMus

Belle journée aujourd’hui à a deuxième collaboration éducative entre l’ASMIQ (Association des Spécialistes en Médecine Interne du Quebec) et le CCUS, lorsque une trentaine d’internistes ont approfondi leur habiletés échographiques.

Tel que promis, et dans l’esprit de #FOAMed, voici les présentations et videos:

Dr. Ian Ajmo nous fait une revue de l’évaluation de la volémie, en particulier l’échographie de la veine cave inférieure (VCI):

présentation PDF gestion-voleěmie – copie

vidéo https://vimeo.com/96308958,

Dr. Anne-Patricia Prévost révise l’échographie pulmonaire et cardiaque ciblée:

presentations PDF ASMIQ 2014 coeur ASMIQ 2014 poumons

vidéos:

https://vimeo.com/96315383,         https://vimeo.com/96315382,

 

Merci aussi à Dr. Simon Benoit et Dr. Nicolas Buissières qui ont fait un travail excellent dans les ateliers pratiques!

 

Philippe

 

A Paradigm shift: re-thinking sepsis, and maybe shock in general… #FOAMed, #FOAMcc

Thomas Kuhn, physicist and philosopher, in his groundbreaking and science changing text, The Structure of Scientific Revolutions, states that:

“Successive transition from one paradigm to another via revolution is the usual developmental pattern of a mature science.”

In other words, a science has growing pains and is bound to have a fair bit of debate and controversy, until a new paradigm becomes dominant.  I think that there is a current – in part prompted by the power of socio-professional media which has allowed minds to connect and knowledge to spread – that will see many of the things that are now “Standard of Care” out the door.

So first of all, the following are must-listens, the first a lecture by Paul Marik, whom I have had the chance to collaborate with in the last years and respect greatly, on knowledge, experience, and even more on his refusal to take anything for granted and being in a seemingly-constant quest for the improvement of medicine.

The second link is Scott Weingart’s take on it, which I think is equally awesome.

I think Paul is pushing the envelope in an essential way, and Scott does a fantastic job of seeing or putting it in perspective. Enjoy:

http://emcrit.org/podcasts/paul-marik-fluids-sepsis/

http://emcrit.org/podcasts/fluids-severe-sepsis/

My (very) humble opinion on this is a rather simple, almost philosophical one:  why are we seemingly obsessed with treating a predominantly vasodilatory pathology with large amounts of volume?  I’ve said this in previous posts and podcasts, but this, in my opinion, is largely cultural and dogmatic. “Levophed – Leave’em dead” is something I heard as a student and resident, and came to take for granted that I should give lots of fluid in hopes of avoiding pressors… But there’s no evidence at all to support this.  The common behavior of waiting until someone has clearly failed volume resuscitation before starting pressors befuddles me (think how long it takes to get two liters of fluid in most ERs…).  If I was in that bed, I’d much rather spend an hour a bit “hypertensive” (eg with a MAP above 70) than a bit hypotensive while awaiting final confirmation that I do, in fact, need pressors.

I strongly suspect that it’s just a matter of improving vascular tone, giving some volume (which may be that 3 liter mark), and ensuring that the microcirculation/glycocalyx is as undisturbed as possible. Now when I say it may be the 3 liters, I firmly believe this will not apply to everyone, and that it will be 1 liter in some, and 4 in others, and that a recipe approach will be better than nothing, but likely harm some.

I think that blind (eg no echo assessment) of shock is absurd, and for anyone to propose an algorithm that does not include point-of-care ultrasound is only acceptable if they are in the process of acquiring the skill with the intention of modifying their approach in the very near future.

The whole microcirculation/glycocalyx is absolutely fascinating stuff, and undoubtedly will come under scrutiny in the next few years, and it is definitely something I will focus on in upcoming posts & podcasts. Our resuscitation has been macro-focused, and certainly it is time to take a look at the little guys, who might turn out to have most of the answers. For instance, there is some remarkable data on HDAC inhibitors (common valproic acid) and their salutatory effects in a number of acute conditions such as hemorrhagic shock (Dr. Alam) which have nothing to do with macro-resuscitation, and everything to do with cell signaling and apoptosis. Hmmm…

please share your thoughts!

thanks

Philippe

Bedside Ultrasound: The Sluggish IVC – something to look for… #FOAMed, #FOAMcc

So take a look at this:

I’m sure most experienced bedside sonographers come across this all the time.  For those who are starting out, and until now have just been looking at size and variation, take a second to look at the flow.  You can actually see the flow stop and start, which tells you your cardiac output is bad.  It could be bad because of the RV, the LV, the pericardium, the tension pneumothorax, anything, but it’s bad.  So just in case you were only gonna look at the IVC, keep looking! You will find something abnormal downstream, perhaps that you can do something about (not fluids, though).

I have seen this disappear and clear up with – when possible – correction of the problem, back to the normally anechoic IVC we usually see.

thanks!

Philippe

ps note there is also a mirror artifact in the right lower portion of the field, making it look as though there are two beating hearts.

Bedside Ultrasound Clip Quiz #3 – #FOAMed, #FOAMcc

This is what you see on the anterior chest of your patient:

What can you conclude?

scroll below for answers…

 

 

 

 

 

 

 

 

 

 

 

 

 

Lung sliding and B lines

The notable findings are:

a. lung sliding – this indicates that there is no pneumothorax in the area you are scanning.

b. there are B lines – this indicates that there is interstitial edema – this has no etiological information and must be coupled with the rest of the ultrasound and clinical examination to make a diagnosis. It could represent CHF, pneumonia, non-cardiogenic pulmonary edema, or any other interstitial process.