**CASE OF THE MONTH** #CARDIOTWITTER I've shared some interesting cases in the past 1yr...but this one is probably the most unique! Not valve related!! 70yrs old patient presents with chest pain. Inferior TWI on ECG, +ve troponin --> NSTEMI Goes to cath lab...

Few places left on our 2 day critical care echo course in the Mater. Max 16 candidates, 2:1 ratio for hands on work. Image interpretation stations. Lectures on the day because we know no one does the pre-reading 😉 . For more details see

@Mater_ICU is open for Culture Night - come and visit us!

🧵regarding the useful technique of 'straightening the wire' during central line placement when the plastic guide is no longer within reach. If you do a lot of central lines (or a lot of percutaneous procedures), this technique will come in handy over and over again. (1/ )

Interns are starting work all over the U.S. this week, so I thought it might be useful to suggest a more practical curriculum for initial orientation:

@msiuba discusses all things pulmonary hypertension at #HR24 Here are some of my biggest take homes including a simple management approach he beautifully outlines👇 My favorite point though... most (almost all!) PH patients do NOT need fluids and need fluid removal when decompensating. --------------------------------------------------------- 2022 Classification of PH mPAP>20 Precap PVR > 2 Postcap PAWP > 15 Combined: elevated PVR and PAWP Lecture's Focus - not on the garden variety group II/III Focus on severe precapillary (PVR > 5) or any PH with significant RV dysfunction or patients on vasodilatory therapies. Cautionary Notes 1. Rare diseases often need expert opinions - contact their PH provider/center. 2. You CANNOT stop the pulmonary HTN therapies, even if hypotensive and hypoxemic. Talk to a PH specialist. If on IV/SubQ therapies you need to get this sorted with pharmacy. No oral intake, need an enteral tube. Early Goal Directed Palliation Consideration Where are they on their disease process? Functional? High risk of PPV CPR unlikely beneficial Candidacy for transport and ECMO? Partial List of Causes of Decompensation 1. Volume overload part of the problem until proven otherwise 2. Infection (indwelling lines?) 3. Arrythmias - 30% of CO from atrial kick can be devastating for this population 4. New VTE 5. Treatment nonadherence Diagnosis Physical Exam Features to look for On IV therapies might have a lot of blushing and asymptomatic hypotension (SBP 80s). Ask what is your baseline? Perfusion exam is the most important - cap refill, UO, mental status. Can be confounded a little bit by flushing of the skin. Filling pressure - JVP vs. ultrasound Peripheral Edema POCUS Parameters to focus on LVOT VTI, Portal vein pulsatiity, and RVOT VTI valuable as these reflect the current state of affairs, and not chronic features (e.g. chronic RV dilation). Portal vein pulsatility a reliable marker of congestion in PH patients (@ArgaizR has done some of this work) Don't rely on.... IVC or TR severity. Not really helpful! Management and Treatment Goals Many PH patients will never have a normal LVOT VTI... hard to normalize often. 1. Preload optimization --> almost certainly reduction. The idea that PH needs volume as a rule is FALSE. MOST NEED REDUCTION. 2. Afterload optimization - keep normal pH, SpO2, CO2 etc. Inhaled pulmonary vasodilatiors. 3. Contractility optimization. They love sinus rhythm. Consider cardioversion early. Maintain SBP > RV systolic pressure (to maintain coronary prefusion). . Inotropes as needed. Keep in mind transplant candidacy throughout. #medtwitter #echofirst #cardiotwitter #cardio #meded #foamed

Wow. #foamed #echofirst