Pete Hart

@ross_prager Hate it when people check the pupils during/immediately after CPR in the context of an awful blood gas, as if fixed/dilated pupils = irretrievable brain injury rather than just representing acidosis-related (?) brainstem/neuromuscular dysfunction.

(3/x) We entered a 'refractory VF' period where we shocked and shocked and shocked. We tried everything: anti-arrhythmic, esmolol, dual defibrillation, and unfortunately ECMO wasn't available. Right as we were about to call the code (now almost 90 minutes of CPR) we did a final pulse check and the patient had a pulse! We did the usual post cardiac arrest care and tests: 1. Blood gas --> horrible 2. CT head --> early loss of gray white differentiation 3. Exam --> GCS3 without motor response 4. Pupils --> fixed and dilated We brought the patient to ICU

(1/x) Determining when to stop performing CPR for patients in cardiac arrest is hard and is not as precise as one might think... This one case from my medical school days changed how I think / approach this 👇

@PARADicmSHIFT @Ruthrespphysio @TimHutchinsonPT @amit_pawa @NixLimerick @ThinkingCC @dan___kim @ross_prager @georgentou1 @dr_shai @drshahrul80 @POCUSFrimley Nice scan. The horizontal fissure separates the upper and middle lobes though, not the lower lobe. The middle lobe is aerated here, and there is no frank atelectasis *in this window* but with it being low volume you might find frank collapse elsewhere if you scan around.

@Ruthrespphysio @TimHutchinsonPT @amit_pawa @NixLimerick @ThinkingCC @dan___kim @ross_prager So, if you see the horizontal fissure whilst scanning, have a quick think if it is where you are expecting it to be, and if not, hunt for the cause. And please trim ET tubes unless you are expecting proning or swelling! @georgentou1 @dr_shai @drshahrul80 @POCUSFrimley

Time for another lung tweetorial! A patient was intubated for pulmonary aspiration. No more secretions were obtained, but the patient was 'stuck' at 30% FiO₂ Here's the lung ultrasound of the right base (left was normal) What does it show?

@NephroP Lots of studies also mention lower complication rates with SC vs IC but support these statements with studies which weren't head-to-head comparisons. Best available data shows no significant difference in complication rate.

@NephroP Lots of enthusiasm about supraclavicular insertion which isn't necessarily supported by data. The advantages of subclavians have been demonstrated with infraclavicular-predominant studies and may not extend to the supraclavicular approach.

Using the Supraclavicular Approach to Ultrasound-Guided Subclavian Vein Cannulation. #POCUS #FOAMed #FOAMcc What’s your preferred approach for subclavian cannulation? 🔗 acepnow.com/article/using-…

@Bob_the_PA @IM_Crit_ And "the CVC migrated into the artery"...

@IM_Crit_ Gotta love the wording. "the subdermal implant migrated from subcutaneous plane into one of the upper extremity veins."

This was a subdermal, plastic, 4 cm long progestin-releasing contraceptive implant which was inserted 6 years prior into the medial aspect of the upper arm above the elbow. The patient was asymptomatic and a wait & watch approach was agreed upon pmc.ncbi.nlm.nih.gov/articles/PMC11…

@drjgutt @PeterRobson29 I do think people are rightly passionate about the ethics of aggressive treatment in older people, but that does need to be balanced with professional courtesy and a humility that your own practice might well be unethical or illegal elsewhere.

@IntensivePerson @PeterRobson29 Thank you. It’s Twitter so folks are mean for the sake of it. The point of the post was sharing interesting findings on ultrasound and more novel approaches to refractory vfib.

This rockstar attitude to resus is sad. "Shame" that he got ROSC so couldn't try DS defib. Whacking the LUCAS and pads on an elderly nursing home resident is not in anyone's best interest. No thought of weighing up the harm Vs benefit and giving this patient a good end of life.

@yuksekyskay @IhabFathiSulima No indication from the video that this is arterially placed. However, if arterial cannulation is suspected, the line should not be removed without consulting a vascular surgeon or interventional radiologist doi.org/10.1111/anae.1…

@IhabFathiSulima central cath, likely in the wrong place, in carotis arter

What is happening and what terribly can go wrong?

@AmputationSuck @austin_mar41968 @IhabFathiSulima It's not the size that makes this *not* a PICC. The clue is the "PI" part.

@austin_mar41968 @IhabFathiSulima Biggest PICC you’ve ever seen?!

@chebbes @DrHuw Hi Chris. Are there guidelines for non-TIVA RSI? If not, should we expect any for TIVA RSI? 2015 DAS guidelines very non-directive re: drug choice. (I'm not a TIVA RSIer, just trying to figure out what the objections are, as I think RSI overall is extremely poorly defined).

@DrHuw It’s an interesting technique to use given the lack of guidance/recommendations for TIVA in rsi, and the fact that cricoid pressure is still part of nationally recognised guidance.

@DrHuw Not a technique I would espouse, but those criticising this (or advocating for thio/sux) could do with being more specific about their reasons. CVS effects of rapid propofol/remi in a sick patient? Excessively slow induction?

@mdonnino @KateMBerg @PulmCrit @PulmPEEPs @BIDMCEM @MHayes_MD @tony_breu @jeremyfaust @AliRaja_MD @HarvardPulm @jandersUF Clinical picture is of a tension pneumothorax so I'd be scanning right anterior chest for an anterior PTx before getting the CXR. Had tension PTx plenty before despite a functioning chest drain posteriorly. I don't see any signs of this on the CXR but that doesn't rule it out.

80 yr male recovering from sepsis (off pressors/weaning from vent) s/p pigtail for pneumothorax 2 days ago now with sudden hypotension (130/80 > 70/30) and severe hypoxia (SpO2 97% on Fio2 .4/PEEP 5 to SpO2 80% despite Fio2 of 1.0/PEEP 15). CXR as seen. Thoughts?

Out of 241 reported incidents of CVC-related arterial trauma, in 75 cases initial checks (if any) failed to identify arterial cannulation. CXR most commonly implicated in this, with blood gas/transduction failing for mostly predictable reasons. What's your department's practice?

@doctimcook @AlCourtney @Anaes_Journal Ha, I did not know that was the reason. Largest published prospective study of CVC complications has only 15 cases of arterial trauma, and in the UK we have close to zero information on how, where, why and by whom CVCs are inserted. I'd be interested in your thoughts on it.

@IntensivePerson @AlCourtney @Anaes_Journal CVC repeatedly rejected as subject of NAP on grounds off too much known about it already….

When a central venous catheter-related arterial trauma incidents occurs.. Who is involved? 37% resident doctors Where is the procedure conducted? 37% critical care What was the intended insertion site? 54% internal jugular vein @intensiveperson #anaesthesia #medicine buff.ly/4kbds1u

@doctimcook @AlCourtney @Anaes_Journal Despite obvious interest in this, our paper was not (and couldn't be) primarily about RFs for arterial trauma; main conclusions concerned "falsely-reassuring" pre-dilatation + post-insertion checks, and predictors of outcome (stroke assoc w delayed Dx + drug administration).

@doctimcook @AlCourtney @Anaes_Journal Some kind of denominator data relatively easy to acquire, but more difficult to "match" to NRLS incidents to permit useful statistical comparison. Surely at this point we just need a "proper" NAP on CVC complications designed to collect high-quality incident AND baseline data?

Arterial trauma is a rare, but potentially life-threatening complication of central venous catheter insertion. In this interrogation of two national databases of incident reports, outcomes included: • stroke (10%) • death (4%) #anaesthesia #medicine buff.ly/4kbds1u

Flowchart of diagnosis, management and patient outcomes for central venous catheter-related arterial trauma incidents #anaesthesia #medicine @intensiveperson buff.ly/4kbds1u

@foi_requests @Anaes_Journal However in my view, we prevent arterial trauma not by identifying who does it most, or where it happens, but by optimising insertion technique - specifically robust and objective pre-dilatation checks. There is very little evidence out there currently on this.

@foi_requests @Anaes_Journal "Thank you for your interest in my article", is how I believe I'm supposed to start this off.. The tables which largely describe the circumstances of insertion in these incidents are indeed of limited use until someone produces better denominator data.