Doug Barber

@NephroP @Rajiv_Sinanan Interesting point. How often are subtle b-lines at the bases a sign of fluid intolerance vs. normal physiology? In the ED we often are looking for the cause of SOB, in which case B-lines are anterior and obvious in pulm edema. But prob need diff approach for fluid tolerance?

@Rajiv_Sinanan I think the same. Turning off THI helps or just use the lung preset if available. Maintaining perpendicular angle is easier with curvilinear than with smaller footprint. Relevant studies 🔗 onlinelibrary.wiley.com/doi/full/10.10… 🔗 pubmed.ncbi.nlm.nih.gov/35527112/

75 yoM aki scr 6.7 proteinuria/haematuria ?gn. Pocus for ecv assessment. Subtle B lines were more easily seen with CL probe vs PA. Anyone share this observation? Added other exams as well, any analysis appreciated. @NephroP @icmteaching @ArgaizR @kyliebaker888 @ThinkingCC

@EUSmkh Pleural effusion, moderator band, coronary sinus I believe

Students: What cardiac view is shown? What does the blue asterisk represent? Residents: What are the yellow and red arrows pointing to? #raysofgray #POCUS #ultrasound #FOAMed #MedEd #emergencymedicine #medicalstudent #resident

@NephroP Nice view of the right renal artery in cross section as well!

👆#POCUS IVC = inferior vena cava Ao = abdominal aorta PV = portal vein GB = gall bladder CA = celiac artery

#POCUS quiz Identify 1, 2, 3 on this normal right upper quadrant scan. POLL in thread 👇 #anatomy #FOAMed

@EUSmkh Sagittal uterus with yolk sac and double decidual sign - IUP!

Students: What plane and sonoanatomy do you appreciate? Residents: What is your interpretation (and what is this sign called)? #raysofgray #POCUS #ultrasound #FOAMed #MedEd #emergencymedicine #medicalstudent #resident

@NephroP Did they have JVD? In my experience, when VExUS is this bad, their ears are wiggling

#POCUS representation of the congestion cascade #MedEd #VExUS

#AKI "Patient reports poor PO intake for the past few days. Held lasix and started gentle hydration" Physical examination 👇 #POCUS #MedEd #IMPOCUS #Nephpearls

@EUSmkh Hi! This looks like a lymph node. Can be due to lymphadenitis or malignancy or just reactive lymphadenopathy

Students: What transducer is being used? What is the structure in the clip? Residents: How does this finding affect your differential? #raysofgray #POCUS #ultrasound #FOAMed #MedEd #emergencymedicine #medicalstudent #resident

@easypocus @ria_dancel @NephroP Great point! And is AC / upper arm PIVs are much more likely to fail than forearm. Safer for pressor infusions and more durable

@ria_dancel @NephroP mine (for difficult access, not for resus) is the radial vein(s): -nobody touches it - ~same size as the artery -at distal 1/3 forearm not that deep -average provider can cannulate the artery (w a 20G 8cm seldinger in our shop) *this is the same skill* #POCUS #FUSIC #FAMUS

#POCUS guided peripheral IV placement 🔗nejm.org/doi/full/10.10… #IMPOCUS #MedEd

@HoosierPocus For VExUS, renal vein Doppler should be done on arcuate/interlobar veins. Not pathological for greater renal veins to be pulsation

@dan___kim Enhanced peritoneal stripe sign consistent with pneumoperitoneum. Keeping in mind that if the colon overlies the liver (Chilaiditis sign), you can get this appearance in RUQ. Can distinguish intra- bowel air from peritoneal air by decreasing depth or switching to linear probe

Patient presents in extremis with hypotension and abdominal pain. This is what you see in the upper quadrants when you attempt to do a FAST. What's the diagnosis? #POCUS

@critconcepts Ah that’s true, prob won’t make a difference and most phased array probes don’t have power doppler anyway

@POCUS_Doug yes, phased array. Our machine doesn’t seem to offer power doppler in the TCD preset, just color?

Started playing with #transcranialdoppler lately, because all these #SCCM talks made it sound pretty rad. Can’t seem to get a transtemporal window for beans. Anyone have tips? #medtwitter #neurocrit

@nephro_superman @NephroP @khaycock2 @ThinkingCC @EchoSoliman @ArgaizR @askrenal @WBeaubien Based solely on the anecdotes of Twitter and one case series, I believe most left heart failure congestion can be safely diuresed to PV pulsatility <50%. Some with severe RH failure might not tolerate further dieresis (but they might)

In this case specifically, what is your opinion regarding the changes happened in IVC HVD PVD vexus score ? N.B The patient improved clinically and laboratory Thanks in advance @nephrop @khaycock2 @ThinkingCC @EchoSoliman @ArgaizR @askrenal @WBeaubien

A 45 years female patient cadiomyopathic admitted with cardiorenal S

@IM_Crit_ Great case. It is a shame when patients get diagnosed with pneumonia, get harmed with fluids, when the Dx by US was there all along

PS: Yes, all are real cases. I have to pick a few interesting points each time, otherwise each case would go on for ever...

ICU stories (from the trenches): 70 yo pt w hx of A-fib/CAD/ICM w EF 25%/VT ablation s/p BiV ICD/CKD/HTN/HLD/peripheral vasc dz/COPD etc presented to outside 🏥 w SOB/weakness/falls. Labs: wbc 15k/creat 3.5 (baseline 2.0)/INR: 8.5/AST/ALT/Tbil: 180/250/3.0, lactate 3.5

@pdsalinas Good point that TAPSE and S’ are just another tool in your toolbox. Visually that is a very sad RV - a finding that even beginner US users would likely pick up on

@NephroP @MayoClinicNeph Keep spreading POCUS! Medicine thanks you for it

Spreading the #POCUS love! Looking forward to meeting the renowned colleagues at @MayoClinicNeph

@Rajiv_Sinanan @NephroP @khaycock2 @ThinkingCC Even in cross section, and considering the side-to-side collapse, IVC looks full to me. Suspect elevated RAP

What do you think of this IVC? Would you proceed with #VExUS? @NephroP @khaycock2 @ThinkingCC

@ArgaizR @ShariqShamimMD @purviparwani @iamritu @onco_cardiology @mandeep_mayo @SinghVasvi @Serginho1409 @ChamsiPash @ASE360 @KemalogluOz @tumleal Have consulted cards for new severe MR on focused US during flash pulm edema/scape. When they came to see hours later after nitro and bipap, the MR disappeared. I swear it was there before! But then remembered that MR and even EF is load dependent

@ShariqShamimMD @purviparwani @iamritu @onco_cardiology @mandeep_mayo @SinghVasvi @Serginho1409 @ChamsiPash @ASE360 @KemalogluOz We have seen it with vasopressin. Severe MR with vasopressin infusion. No/trivial MR after vaso withdrawal @tumleal

Anyone has observed this during TEE. SBP 90s at the start of TEE with trace MR, Phenylephrine bolus leads to severe MR! No resting MR seen on TTE. Symptom of DOE. @purviparwani @iamritu @onco_cardiology @mandeep_mayo @SinghVasvi @Serginho1409 @ChamsiPash @ASE360 @KemalogluOz

@nephneev @NephroP Nice work. Small point but you may want to try lowering your baseline and decreasing your scale for the PV.

@NephroP Thank you for the lateral window tip. Was very helpful. Any comments/suggestions on this one?

66 F with saddle PE s/p mechanical thrombectomy, no right heart strain. On vent. Started having gradual decline in hourly UO (100->50->20). On PE-no pedal edema/crackles On bedside echo-No RV volume overload/diastolic septal flattening on PSAX But, this is what VExUS showed:

@Asiritrauma1 Were they trying to decompress the heart

What's wrong with this picture? Stab chest (posterior) Left paraspinal at T2 Tachypneic desaturating Peripheral hospital doctors decided to do needle decompression then transfer to MTC #TraumaCommonSense

@NephroP Is that falciform ligament?

👆#POCUS

#POCUS quiz Which of the following does this image demonstrate? Approximate transducer position shown. POLL in thread below #MedEd #IMPOCUS #FOAMcc