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How many times have you heard: “Patient's MAP is 50! What pressor should we start?”
A 🧵on shock and pressors... /1
Matt Tsai
514 posts
Matt Tsai
@thematttsai
Hospitalist MD @BIDMC_IM @harvardmed via @UVMLarnerMed • Christian • Med Educator + Innovative Teaching |🫀🫁 Crit Pathophys Aficionado | Opinions my own. 🤙
- Took some time last week to focus on my own learning gaps regarding DIGOXIN 💊 What are its 2 main indications? How does it work for those indications? How do we monitor toxicity and how do we treat? This is what I've learned, in a tweetorial🧵(graphic at the end!) /1
- Spent yesterday reviewing some common coagulation 🩸labs and their interpretations. Here is a graphic I made as a refresher🙂 Keep reading for a few additional points on PT and PTT. /1
- First time on the wards as a senior resident this week, with @ShreyaTrivediMD as my attending (talk about pressure to impress)! I'm prepping a talk to my interns on Acute Kidney Injury. Here is a tweetorial 🧵 on how I think about AKI. Take-home graphics at the end!😀 /1
- I am fascinated by Right❤️Catheterizations and wish I had learned how to interpret its results earlier than I did in my intern year. Sharing some of the lessons I've been taught in this graphic (thanks to @ShreyaTrivediMD for extensive feedback and support)!
- Replying to @thematttsaiThanks for following along! 🙂 Hope you enjoyed this thread as much as I enjoyed making it. Shoutout to @BIDMC_IM PCCM Dr Ginny Brady for her feedback! /END
- Replying to @thematttsaiFirst let’s review🚨SHOCK: a state of decreased perfusion enough to cause end organ damage (AKI, mental status change, elevated LFTs etc). Not all shock requires a low blood pressure, but thinking about shock in terms of low MAP can be helpful to organize its etiologies 👇 /2
- Replying to @thematttsaiDobutamine and milrinone are ino-dilators: they ⬆️ inotropy while⬇️SVR. This can be useful in structural cardiogenic ♥️ shock when poor cardiac output is the issue and afterload reduction is key to offloading the heart. See how these compare to other pressors 👇 /8
- Replying to @thematttsaiNorepinephrine is usually🥇first-line in vasodilatory shock, e.g. septic shock. It acts primarily on alpha 1 (+ some beta 1) receptors resulting in vasoconstriction with mild inotropy. Great for Low SVR states like sepsis! 👇snapshot of @SCCM Surviving Sepsis Guidelines /5
- Replying to @thematttsaiPhenylephrine is a pure alpha 1 agonist, offering vasoconstriction without any inotropy. In fact it can often cause reflex bradycardia. Ideal for Afib RVR with hypotension, in situations where cardioversion 🌩️fails or is not feasible. /11
- Replying to @thematttsaiLastly, remember that NOT all shock should be managed with pressors. 🥤Resuscitate Hypovolemia. 🛠️Fix Obstruction. 💊Treat hypothyroidism or adrenal insufficiency. 🧐Consider mixed etiologies. /14
- Replying to @thematttsaiContrast w/ Vasopressin, a pure vasoconstrictor by V1 receptor agonism and common adjunct to Norepi. VASST trial found no overall mortality difference in septic shock between Norepi + Vaso compared to Norepi alone…but did find benefit among 1 subgroup: less severe sepsis. /6
- I've been spending this month on the infectious disease service🦠and thinking more deeply about a favorite antibiotic on the wards...vancomycin! Why do we use it and when does it *actually* work? Sharing what I've learned in a🧵 1/n #medtwitter #medstudenttwitter
