Skyler Lentz
@SkylerLentz
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Dad x 3| Intensivist and Emergency Physician| Passionate about treating and explaining abnormal physiology| Tweets are opinion only
Vermont, USA
Joined October 2012
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Difficult truths of medicine:
💉A procedure performed expertly may still have a complication
📝A thoroughly obtained history may still lead to the wrong diagnosis
⚖️Excellent patient care may still lead to a complaint
Stay humble, keep learning 📚
What advice do you have?
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A patient presents in shock:
BP is 100/35
A wide pulse pressure (low diastolic) is suggestive of a distributive shock
With an important exception
👇
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#FOAMcc
#foamed
#MedTwitter
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Can epinephrine cause hypotension?
A patient is transferred the ICU with hypotension on 4 mcg/min (.05 mcg/kg/min) epinephrine. Thought to be a GI bleed, resuscitated but was still hypotensive with a HR in the 60s, BP100/40 (60)
Takes carvedilol
Epi stopped MAP 60->90 🤯
How
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You intubated the asthmatic! What to look for on the vent and what to do about it.
It gets complicated, but the basics are in the thread below
#foamcc
#foamed
#tweetorial
mini
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Pulmonary embolisms are tricky 🧐
Beware of the athlete who says...I got short of breath while doing my usual 50-100 mile bike ride and 10 mile hike
HR 70, 97%, looks great
Dx bilateral lobar PE
💡those with ⬆️ physiologic reserve present differently, SOB=consider PE
#FOAMed
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📜Lessons:
✔️Not everything is septic shock
✅Normal LV/RV function does NOT rule cardiogenic cause of shock-low cardiac output from MR+AS despite normal EF in this case
☑️Severe MR can cause unilateral pulmonary edema
✔️Narrow pulse pressure (BP 80/60) hints at cardiac cause
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It's hard to remember which receptors all the vasopressors and inotropes hit 🤷♂️
🚨But we must know the cardiovascular effects of these medications so we can choose the right one for our patient
Simplified version 👇
Even easier: when in doubt choose norepinephrine
#FOAMed
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Using a BVM with a PEEP valve and good technique on a de-recruited lung improves atelectasis, increases FRC and ultimately increases safe apneic time with
@mattroginski
@ResusPadawan
@DarrenBraude
#CCTMC19
procedural anatomy lab
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🫁Vent Management COVID ARDS🫁
Failing max NiPPV, RR 40s, O2 70s to low 80s->intubate
😧Post intubation O2 sat 88%, VC-AC Vt 5 ml/kg, PEEP 18, fiO2 100%, plateau 35
4 hours later..
🙂Sat 96%, 60% O2, Pplat 30-31
What did we change to improve over those 4 hrs?
#FOAMed
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@sargsyanz
Ha we must have gotten the same kit. I was similarly puzzled
I think we concluded it is a hearing test
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Crashing asthmatic?
@mattroginski
says
Albuterol 20 mg/hr, IV epi 5 mcg/min
NIV-Bilevel start 10/5 & increase IPAP if WOB remains high
Remain calm, try opioids for air hunger, precedex, low dose benzo,
Reserve ketamine for RSI
Intubate only if failing
#stoweem23
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Tips on the mechanically ventilated ARDS and sick hypoxemic patient.
Protect the lungs from the start! See the basics below.
#Tweetorial
#foamcc
#foamed
Based on prior work with
@mattroginski
@roo_atchinson
@UVM_EM
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Echo next morning gives the diagnosis:
Severe AS
+
Acute chordae tendineae rupture with severe MR
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Epi is thought of as a inoconstrictor
(Increased inotropy and vasoconstriction)
But, I have had few cases (like this one) where at low doses it acts more like an inodilator (inotropy and vasodilation)
I like this visual
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It is related to the dose dependent effects of epinephrine
At lower doses (<.1 mcg/kg/min) it has more beta 1 and beta 2 activity than alpha 1 (vasoconstriction)
Beta 1 increases inotropy (⬆️ stroke volume) and chronotropy (⬆️ HR)
Beta 2 reduces vascular tone (vasodilates)
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A narrow pulse pressure ~ BP 80/60 makes me think low cardiac output and high SVR
Simplistically, the stroke volume is low so a high systolic pressure is not generated
Compensation = increase SVR and a higher diastolic pressure
Causes cardiogenic shock, hypovolemia, etc.
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One important exception is:
🫀Severe Aortic Regurgitation
The incompetent aortic valve allows blood to move retrograde during diastole (reduced forward cardiac output) and a lower diastolic pressure and a wider pulse pressure is observed
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💔 How to approach cardiogenic shock in the ED💔
@UVMEmergencyMed
didactics
1. Stabilize and restore perfusion
2. Diagnose and treat underlying cause
#FOAMed
My general approach to stabilization:
👇
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Work hard to save someone's life on your last shift?
Go visit them in the ICU. The family (and ICU team) will be confused but happy to see you.
Let your team know they did a good job.
Helps remind us all what we do matters.
#FOAMed
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Final thoughts 📜
CAN have a metabolic acidosis with a normal bicarb
2.Always calculate an anion gap
3.Use Delta anion gap-Delta Bicarbonate to identify mixed acid base disorder
4.Metabolic alkalosis from hypovolemia and vomiting-treat with NS
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Ordering an isotonic sodium bicarb infusion for a patient with acute renal failure/non gap acidosis:
⛔️ Computer warning THIS 150meq EXCEEDS THE RECOMMENDED DOSE of NaHCO3🤦♂️
👇
We need one for Normal Saline
⛔️THIS EXCEEDS THE RECOMMENDED DOSE OF CHLORIDE by 1000%
#FOAMcc
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Can you be in shock and HYPERtensive?
I think so. Our patients teach us many lessons
#FOAMed
#FOAMcc
@UVMEmergencyMed
👇
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100
When I see a BP of 100/35 I think of a low SVR (vasodilated) state and imagine the simplified equation
Mean arterial pressure ⬇️= cardiac output ↔️x systemic vascular resistance ⬇️
Common causes: sepsis, anaphylaxis, iatrogenic (vasodilators), etc
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🫁A non-invasive approach to respiratory failure🫀
Be an expert at keeping your patient off the vent!
@UVMEmergencyMed
didactics discussing the basics and cutting edge on one of my favorite subjects
#FOAMed
#FOAMcc
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🚨🫁 Ventilator Peak Pressure Alarms
How to approach?
In volume targeted modes of ventilation I check the plateau pressure- if normal probably an airway resistance problem
High plateau-I look for a "compliance" problem
What tips do you have?
In a visual 👇
#foamed
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Best second line agent in status epilepticus?
Valproate, levetiracetam or fosphenytoin seem to be equally effective in this study.
Use whatever is most readily available.
*Note it's not "1 gram of keppra"
Levetiracetam was dosed at 60mg/kg to a Max of 4.5 gm.
#foamed
#foamcc
Intravenous valproate, levetiracetam, and fosphenytoin stopped status epilepticus that was resistant to initial treatment with lorazepam in approximately half the patients and did not differ significantly in effectiveness.
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The conflict of practicing emergency medicine:
I hope I didn't miss anything or fail to treat something that may harm my patient
.
.
.
I hope I didn't do unecessary treatments, procedures or testing that may harm my patient
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Don't miss cardiogenic shock in the ED!
High mortality that increases when diagnosis is delayed
Use careful exam, labs, ECG and POCUS to dx
A few tips from our recent paper Madison Daly
@long_brit
@EMHighAK
@UVMEmergencyMed
#foamcc
#FOAMed
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Your patient with septic shock is improving w/ stable dose of 10-15 mcg/min norepi but goes into & stays in a-fib w/ rate >140-160
No other contributors found, had adequate volume, ❤️ is ok
What are you using 1st for rapid a-fib in patient w/ septic shock? Why?
#foamcc
#FOAMed
Diltiazem
314
Esmolol
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Amiodarone
940
Something else/Comment
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Appropriate and aggressive diuresis is a necessary critical care skill.
How do you know a
#diuresisjedi
like
@PulmCrit
is in the ICU?
@morganpcc
👇 Volume on
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Metabolic acid base disorders can be difficult to identify and manage in the ED 🧪
Check out our ED focused review with
@AckilDaniel
@DocWillisMD
#FOAMed
Figure on approach to metabolic acidosis 👇
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🚨When evaluating for shock remember gut = end organ.
Pt w/ lightheadedness after starting dilt for a fib
HR ~50 BP 90s/50s
Alert, looks ok
In shock? 🤷♂️
Soon has new, severe abd pain, lactate now ⬆️
Intestinal ischemia 😲
Start epi->pain goes away in <30 min, CT normal👌
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Common cause is infective endocarditis
Can be tricky with wide pulse pressure & maybe fever from bacteremia
If wide pulse pressure and signs of heart failure and/or diastolic murmur consider acute aortic insufficiency
What tips do you have?
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We recently had to perform an emergent, bedside pericardiocentesis.
It was difficult to quickly find a kit that worked...
What was available and worked best for us?
#FOAMcc
#FOAMed
@PatrickNeilan3
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How do you manage massive hemoptysis in the ED? 🩸🫁
@roo_atchinson
@long_brit
@mattroginski
et al.
Our thoughts 👇
The emergency department evaluation and management of massive hemoptys...
#FOAMed
#foamcc
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Definitive Treatment is surgical
Temporary medical management targets shortening diastolic time (reduce time for retrograde flow into LV) and reducing afterload (SVR)
Can be achieved with medications such as:
Epinephrine (at lower doses)
Or
Dobutamine
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What are the can’t miss EM/CCM papers of the past year? 📄
Giving a talk on top EM/CCM articles and don’t want to miss any
Which are your favorites EM relevant critical care articles?
#FOAMcc
#stoweem23
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What are your favorite tips on the ED management of the critically ill patient with cirrhosis?
A few of mine
#FOAMed
#FOAMcc
#Tweetorial
👇
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A patients presents to your ED with fatigue, polyuria, glucose of 300 mg/dl, no sign of DKA on labs. Now what?
The ED will see these patients and we should be ready to start treatment for new diabetes
Management options👇
@RxEmergency
@long_brit
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In my patient:
The beta blocker likely caused the low dose epi to not increase chronotropy or inotropy but still had the beta 2 effect of vasodilation causing hypotension
Or if
MAP = cardiac output x systemic vascular resistance
We got a drop in SVR with no ⬆️ CO
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Lessons 📝
-Individualize PEEP
-Think about the alveolar/capillary unit, overdistension, and risk of worsening v/q matching
-Unilateral or focal lung processes are not ARDS and may not improve with high PEEP if there is not recruitable lung
What tips do you have?
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Took the opportunity to write "kaliuresis" in my ED note today.
Pearl: Add a thiazide to the high dose loop diuretic in the acute, severely hyperkalemic patient for maximal kaliuresis
#FOAMed
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Presented to the ED with acute onset dyspnea, new O2 requirement 6 L NC, minimal PMH
BP 95/70, HR ~ 100, afebrile
Hypoxemia worsened during ED stay requiring intubation
Now hypotensive
CT obtained with unilateral right sided pulm infiltrates, small pleural effusions, no PE
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Lesson: always calculate an anion gap, even if bicarb is normal
What is going in our case?
Use Delta-Delta equation to figure it out
Delta (change in anion gap) - Delta (change in bicarb) = ± 5 in pure HAGMA
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🛌Arrival to ICU
B: 50% FiO2 PEEP 10
C: BP 80/60 HR 120s on
Norepi 40 mcg/min
Vasopressin .03 u/min
Epi 5 mcg/min
Distal extremities cool, oliguric, systolic heart murmur heard over vent (old per notes)
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Middle of night POCUS 🫀
RV mildly dilated but systolic function looks ok
IVC 2.5 cm minimal variation
LVEF is normal
AS suspected on visual assessment
Comprehensive echo ordered for better valve assessment in AM
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🚨Mechanical Ventilation tips in COVID-19
As COVID-19 ramps up again, here are our thoughts on initial ED mechanical ventilation in COVID ARDS
@mattroginski
@EMinMiami
@MRamzyDO
@MGottliebMD
@long_brit
@ELS_Emerg_Med
#FOAMed
#FOAMcc
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Post arrest shock is complex & heterogeneous. There’s unlikely a “ best pressor” for all
Best advice:
Try to classify shock
Cardiogenic w/ LV failure-low dose epi or norepi + dobutamine
Vasoplegic/distributive-norepi +\- vaso
Unsure? Norepi
Thanks
@EMPHARM_NET
for the data!
Our latest paper 🚑🚨: a systematic review comparing norepinephrine vs epinephrine for post-cardiac arrest shock 🫀
@Nimbex2001
@bfaine1
@MeganARech
@CBthePHARMD
@giles_slocum
@nacquisto
@LRayRx
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Thank you
@umassEMresident
for having me come talk about two of my favorite subjects.
Cardiogenic shock and non-invasive ventilation.
I hope it can be in person next time!
Summary Slides:
👇
#FOAMed
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Must be pneumonia and sepsis, right?
Time, antibiotics, source control...
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"Sometimes the best thing is to do nothing" when thinking about giving a fluid bolus
@pulmcrit
#zentensivist
#StoweEM20
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Tips:
Shock = hypoperfusion
Shock is NOT a blood pressure
Examine distal extremities as it might be the first clue
Afterload reduction to improve forward flow & ⬆️ CO in high SVR cardiogenic shock
POCUS helps
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Labs 🧪
WBC 20k
Troponin mild elevation
Lactic acid 5.0
Cr mild elevation
U/A with > 50 WBC
Antibiotics, 2 L IVF given and admitted to ICU
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🚨Not all "pneumonias" are caused by infections🫁
A patient presents to the ED for failure of outpatient antibiotics. There are bilateral infiltrates on CXR read as "multifocal pneumonia." No fever, +dry cough, +dyspnea.
Taking an immune checkpoint inhibitor for NSLC
#FOAMed
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@ryan_barnicle
@reverendofdoubt
@MadtownEM
Had a case of DKA with a normal serum bicarbonate (vomiting and a lot of calcium carbonate created a remarkable alkalosis)
That was a tough one, had to convince everyone of DKA treatment with a nice delta-delta discussion 🤓
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Initial ED vent strategies for ARDS/COVID-19
@mattroginski
@MRamzyDO
@EMinMiami
@long_brit
@MGottliebMD
When we wrote this last year I had hoped we wouldn’t be routinely managing severe ARDS in the ED for very long but here we are again.
#FOAMed
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Approach to intubating the hypotensive patient by
@mattroginski
from
@dhart_hems
@dartmouthem
1. Access
2. Pressure bag with volume if hypovolemic
3. Pause and think
4. Vasopressor infusion started early is likely safer than push dose
@UVM_EM
grand rounds
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ICU colleagues,
Next time the ED calls, let the team know when you extubate that good save they cared for.
They don't hear it enough.
#foamcc
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Take homes on HFNC:
-It is a first line therapy in hypoxemic respiratory failure
-Reduces intubation compared to conventional O2
-Probably better than NIPPV in pneumonia (unless you have helmet NIV)
-Monitor close for signs of failure, don’t delay necessary intubation
#CCC50
Live Q&A non invasive respiratory support
@KitTainter
@SkylerLentz
@kdlamb1
@BrianFullerMD
#CCC50
@SCCM
#EMCCM
#EmergencyMedICU
#RT
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Opinions on Sodium Bicarb 🚨
You have a patient with a severe lactic acidosis (Metformin), gas 6.95/PaCO2 18/Bicarb 5, RR 30, shock, declining MS, intubation imminent & unavoidable
Do you give a slow push amp or two of sodium bicarb prior to induction? Why y/n?
#foamcc
#FOAMed
Yes
458
No
191
Depends/show answers
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@NephroP
Nice table!
I like to think about the dose dependent effects of epinephrine
Low dose (<0.1 mcg/kg/min) probably is more B1 and B2; higher doses add alpha/vasoconstriction
For this reason low dose epi can be a decent option in RV failure/pHTN w/ shock
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Thank you
@CriticalCareNow
and
@resus_x
crew at
#Resusx2022
for inviting me to talk to about adrenal insufficiency
Summary slide if you missed it
👇
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Sepsis infographic 👇
Note 30 ml/kg fluid is a guideline recommendation ONLY if lactate >4 or hypotensive.
*Not everyone with sepsis is mandated to get 30 ml/kg by guideline
Whether everyone with septic shock needs 30 ml/kg fluid if a seperate discussion..
#foamed
#FOAMcc
Improve sepsis and septic shock response with the
#SurvivingSepsis
Campaign’s Hour-1 Bundle. Access resources to help clinicians use the bundle including an infographic, pocket card, and videos:
#SCCMSoMe
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How do you evaluate and manage alcoholic ketoacidosis in the ED?
Our thoughts
@long_brit
@MGottliebMD
#foamed
@jem_journal
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Don’t miss euglycemic on your next shift!
Check out our most recent paper on evaluation and management of EuDKA
@MGottliebMD
@EMHighAK
@long_brit
#FOAMed
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#COVIDARDS
w/ worsening hypoxemia after a few days on the vent.
PaO2 of 60 on 100% FiO2 and PEEP 14 (adj to best compliance) 😲
4 hrs later
👇
PaO2 of 110
By morning FiO2 ⬇️ 60%
How? Fancy vent modes? Exp meds?
No! just proning.
Don't forget the basics!
#FOAMed
#foamcc
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Is there an acidosis?
The pH is normal, bicarb is normal 🧐
What’s the anion gap?
130 – [75+25] = anion gap of 30
There is an elevated anion gap = there IS a high anion gap metabolic acidosis (HAGMA)
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Want to learn about vent management in the ED?
Check out our vent workshop! Rebellion 2020 in San Antonio June 5.
Hands-on with EM/CCM instructors!
@mattroginski
@srrezaie
Register at
#FOAMed
Why is the vent alarming! Why is the peak pressure high?
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Tips:
Look for air trapping on flow waveform
Decrease RR to maximize expiratory time, as low as 10-15/min
Keep plateau pressure < 30
Tolerate a respiratory acidosis and deeply sedate +/- paralyze if needed
Maximize bronchodilators
V-V ECMO if unmanageable on the vent
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Nice comparison of 3% hypertonic saline strategies for correction of hyponatremia
#FOAMcc
Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion for Symptomatic Hyponatremia via
@JAMAInternalMed
part of
@JAMANetwork
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Fever and tachycardia does not equal 30ml/kg fluid
Fever and tachycardia does not equal 30ml/kg fluid
Fever and tachycardia does not equal 30ml/kg fluid
Fever and tachycardia does not equal 30ml/kg fluid
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@jasonkbowman
Totally agree.
One of the scribes I work with puts the patient's name in the HPI and I really like it.
Instead of "The patient states..."
Better:
"Bill said the chest pain began yesterday while walking his golden retriever named Max."
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All of these have to be present for a fluid bolus to be of clinical benefit.
@PulmCrit
#StoweEM20
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Agree!
Those on HFNC can meet the diagnosis of ARDS and should be included in the Berlin definition.
A flow cutoff of >30 L/min makes sense as a substitute for a PEEP cutoff.
#foamcc
NEW Viewpoint—The Berlin definition of
#ARDS
: should patients receiving high-flow nasal oxygen be included?
From Prof Michael Matthay & colleagues
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