1/ Volume Assessmentโฆ โฆ is hard
Physical exam for hypovolemia, a thread
Physical exam for hypovolemia, a thread
2/ Is the above patient?
3/ What do we mean by โ๐ฑ๐ฟ๐โ? By ๐๐ผ๐น๐๐บ๐ฒ ๐๐๐ฎ๐๐๐?
๐๐ฒ๐ต๐๐ฑ๐ฟ๐ฎ๐๐ฒ๐ฑ is often ~ hypertonicity / intracellular volume contraction
๐ฉ๐ผ๐น๐๐บ๐ฒ ๐ฑ๐ฒ๐ฝ๐น๐ฒ๐๐ถ๐ผ๐ป is โextracellular volume w/ blood volume contraction
bit.ly
๐๐ฒ๐ต๐๐ฑ๐ฟ๐ฎ๐๐ฒ๐ฑ is often ~ hypertonicity / intracellular volume contraction
๐ฉ๐ผ๐น๐๐บ๐ฒ ๐ฑ๐ฒ๐ฝ๐น๐ฒ๐๐ถ๐ผ๐ป is โextracellular volume w/ blood volume contraction
bit.ly
4/ But are we really wondering ๐๐ต๐ฒ๐๐ต๐ฒ๐ฟ ๐ผ๐ฟ ๐ป๐ผ๐ ๐๐ผ ๐ด๐ถ๐๐ฒ ๐๐ฉ๐?
Is my pt ๐ณ๐น๐๐ถ๐ฑ ๐ฟ๐ฒ๐๐ฝ๐ผ๐ป๐๐ถ๐๐ฒ or at least ๐ณ๐น๐๐ถ๐ฑ ๐๐ผ๐น๐ฒ๐ฟ๐ฎ๐ป๐, bit.ly?
๐๐ฏ๐ฅ ๐ฌ๐๐๐ฉ ๐๐ก๐ช๐๐ ๐ต๐ฐ ๐จ๐ช๐ท๐ฆ, ๐ฃ๐ช๐ต.๐ญ๐บ/3๐จ๐8๐ฆ๐ต๐ฑ
A separate discussion
Is my pt ๐ณ๐น๐๐ถ๐ฑ ๐ฟ๐ฒ๐๐ฝ๐ผ๐ป๐๐ถ๐๐ฒ or at least ๐ณ๐น๐๐ถ๐ฑ ๐๐ผ๐น๐ฒ๐ฟ๐ฎ๐ป๐, bit.ly?
๐๐ฏ๐ฅ ๐ฌ๐๐๐ฉ ๐๐ก๐ช๐๐ ๐ต๐ฐ ๐จ๐ช๐ท๐ฆ, ๐ฃ๐ช๐ต.๐ญ๐บ/3๐จ๐8๐ฆ๐ต๐ฑ
A separate discussion
5/ Focus: hypertonicity, ๐ง๐๐ฟ๐ด๐ผ๐ฟ & ๐๐
๐ถ๐น๐น๐ฎ๐ฟ๐ ๐ฆ๐๐ฒ๐ฎ๐, per McGee, bit.ly โจ mod helpful
๐๐จ๐ฏ๐ฐ๐ณ๐ฆ ๐ฎ๐ถ๐ค๐ฐ๐ถ๐ด ๐ฎ๐ฆ๐ฎ๐ฃ๐ณ, ๐ต๐ฐ๐ฏ๐จ๐ถ๐ฆ ๐ง๐ถ๐ณ๐ณ๐ฐ๐ธ๐ด, ๐ด๐ถ๐ฏ๐ฌ๐ฆ๐ฏ ๐ฆ๐บ๐ฆ๐ด. ๐๐ช๐ง๐ง๐ช๐ค๐ถ๐ญ๐ต ๐ต๐ฐ ๐ด๐ต๐ข๐ฏ๐ฅ๐ข๐ณ๐ฅ๐ช๐ป๐ฆ =๐ฑ๐ฆ๐ณ๐ง๐ฐ๐ณ๐ฎ๐ข๐ฏ๐ค๐ฆ
๐๐จ๐ฏ๐ฐ๐ณ๐ฆ ๐ฎ๐ถ๐ค๐ฐ๐ถ๐ด ๐ฎ๐ฆ๐ฎ๐ฃ๐ณ, ๐ต๐ฐ๐ฏ๐จ๐ถ๐ฆ ๐ง๐ถ๐ณ๐ณ๐ฐ๐ธ๐ด, ๐ด๐ถ๐ฏ๐ฌ๐ฆ๐ฏ ๐ฆ๐บ๐ฆ๐ด. ๐๐ช๐ง๐ง๐ช๐ค๐ถ๐ญ๐ต ๐ต๐ฐ ๐ด๐ต๐ข๐ฏ๐ฅ๐ข๐ณ๐ฅ๐ช๐ป๐ฆ =๐ฑ๐ฆ๐ณ๐ง๐ฐ๐ณ๐ฎ๐ข๐ฏ๐ค๐ฆ
6/ ๐๐
๐ถ๐น๐น๐ฎ๐ฟ๐ ๐ฆ๐๐ฒ๐ฎ๐ performed 2 ways
1.Apply ๐ฝ๐ฟ๐ฒ๐๐ฒ๐ถ๐ด๐ต๐ฒ๐ฑ ๐๐ถ๐๐๐๐ฒ to the patientsโ right axilla for 15 min, weigh after bit.ly
2.Use ๐บ๐ผ๐ถ๐๐๐๐ฟ๐ฒ ๐ถ๐บ๐ฝ๐ฒ๐ฑ๐ฎ๐ป๐ฐ๐ฒ ๐บ๐ฒ๐๐ฒ๐ฟ was applied to axilla bit.ly
NOT PRACTICAL
1.Apply ๐ฝ๐ฟ๐ฒ๐๐ฒ๐ถ๐ด๐ต๐ฒ๐ฑ ๐๐ถ๐๐๐๐ฒ to the patientsโ right axilla for 15 min, weigh after bit.ly
2.Use ๐บ๐ผ๐ถ๐๐๐๐ฟ๐ฒ ๐ถ๐บ๐ฝ๐ฒ๐ฑ๐ฎ๐ป๐ฐ๐ฒ ๐บ๐ฒ๐๐ฒ๐ฟ was applied to axilla bit.ly
NOT PRACTICAL
7/ ๐ง๐๐ฟ๐ด๐ผ๐ฟ, the last PE finding standing?
How to:
Positive when >3 sec after 3 sec of pinching subclavicular* skin (bit.ly)
๐๐ฉ๐ช๐ด ๐ฑ๐ต ๐ฉ๐ข๐ฅ ๐ฅ๐ช๐ข๐ณ๐ณ๐ฉ๐ฆ๐ข ๐ข๐ฏ๐ฅ ๐๐ข 157. ๐๐ช๐ฅ ๐ ๐ฏ๐ฆ๐ฆ๐ฅ ๐ต๐ถ๐ณ๐จ๐ฐ๐ณ ๐ต๐ฐ ๐ค๐ฐ๐ฏ๐ง๐ช๐ณ๐ฎ ๐ด๐ฉ๐ฆ ๐ฏ๐ฆ๐ฆ๐ฅ๐ฆ๐ฅ ๐5๐?
How to:
Positive when >3 sec after 3 sec of pinching subclavicular* skin (bit.ly)
๐๐ฉ๐ช๐ด ๐ฑ๐ต ๐ฉ๐ข๐ฅ ๐ฅ๐ช๐ข๐ณ๐ณ๐ฉ๐ฆ๐ข ๐ข๐ฏ๐ฅ ๐๐ข 157. ๐๐ช๐ฅ ๐ ๐ฏ๐ฆ๐ฆ๐ฅ ๐ต๐ถ๐ณ๐จ๐ฐ๐ณ ๐ต๐ฐ ๐ค๐ฐ๐ฏ๐ง๐ช๐ณ๐ฎ ๐ด๐ฉ๐ฆ ๐ฏ๐ฆ๐ฆ๐ฅ๐ฆ๐ฅ ๐5๐?
8/ What about ๐ผ๐ฟ๐๐ต๐ผ๐๐๐ฎ๐๐ถ๐ฐ๐?
For hypovolemia not helpful (bit.ly)
For hypovolemia not helpful (bit.ly)
9/ Early studies phlebotomized (i.e.
๐ฏ๐น๐ผ๐ผ๐ฑ ๐น๐ผ๐๐, not hypertonicity) moderate (450-630 mL) to large (630 โ 1150 mL) amounts of blood
โฅ20 mm Hg โ SBP was 9% sensitive for moderate blood loss! Better maybe actually a pulse โโฅ30/ or just subjective severe dizziness
๐ฏ๐น๐ผ๐ผ๐ฑ ๐น๐ผ๐๐, not hypertonicity) moderate (450-630 mL) to large (630 โ 1150 mL) amounts of blood
โฅ20 mm Hg โ SBP was 9% sensitive for moderate blood loss! Better maybe actually a pulse โโฅ30/ or just subjective severe dizziness
10/ What about ๐ฐ๐ฎ๐ฝ๐ถ๐น๐น๐ฎ๐ฟ๐ ๐ฟ๐ฒ๐ณ๐ถ๐น๐น ๐๐ถ๐บ๐ฒ?
For hypovolemia it might be โuselessโ bit.ly
For hypovolemia it might be โuselessโ bit.ly
11/ CRT to assess ๐ฝ๐ฒ๐ฟ๐ถ๐ฝ๐ต๐ฒ๐ฟ๐ฎ๐น ๐ฝ๐ฒ๐ฟ๐ณ๐๐๐ถ๐ผ๐ป maybe not.
But should we measure it as in ANDROMEDA-SHOCK bit.ly?
โขFirm pressure to ventral right index finger with
๐ด๐น๐ฎ๐๐ ๐๐น๐ถ๐ฑ๐ฒ for 10 sec
โขNl skin color with chronometer, CRT >3 sec = abnl
But should we measure it as in ANDROMEDA-SHOCK bit.ly?
โขFirm pressure to ventral right index finger with
๐ด๐น๐ฎ๐๐ ๐๐น๐ถ๐ฑ๐ฒ for 10 sec
โขNl skin color with chronometer, CRT >3 sec = abnl
12/ A word on volume responsiveness, it doesnโt seem like any exam maneuver discussed is predictive โน๏ธ(bit.ly)
The closest thing might be a passive leg raise, but this depends on dynamic assessments of cardiac output (or surrogates)
The closest thing might be a passive leg raise, but this depends on dynamic assessments of cardiac output (or surrogates)
And volume assessment, next level:
The "correct" answer was dehydration. More accurately turgor has been moderately helpful in predicting ๐ต๐๐ฝ๐ฒ๐ฟ๐๐ผ๐ป๐ถ๐ฐ๐ถ๐๐.
While elasticity increases with age, the study - pinching subclavicular 3 sec, abnl if >3 sec was in pts >65 yrs so esp valid in this age group
While elasticity increases with age, the study - pinching subclavicular 3 sec, abnl if >3 sec was in pts >65 yrs so esp valid in this age group
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