UDLCO summary :
CME India is a popular continuing medical education (recently termed continuing professional development) platform in India and CSI aka cardiology society India has it's own platform and this UDLCO merges two discussions in two different platforms using a common thread. The CME India thread begins with a professor of cardiology posting his case report around raised abdominal pressures causing a cardiogenic shock mimicker that was helped using a simple abdominal decompression using a flatus tube. This illustrates how a general medical cognition is always necessary even in cardiology that is often considered a focused area although the human organs are all connected in the same body and arise from a general embryological unit of stem cells as much as different specialities have been born from a common general medicine father.
Keyword glossary : http://userdrivenhealthcare.
Conversational transcripts initially through a quiz presented by a Prof of cardiology and an ensuing debate hinting at the current tension between case based and evidence based reasoning :
[11/23, 1:11 PM] S M: *_Educational post*_ *_CCU caregivers_ *
A septuagenarian male, known case of ischaemic cardiomyopathy with severe biventricular dysfunction, presented with recurrent ventricular tachycardia, cardiogenic shock with multiorgan dysfunction. He improved with conservative management and serum creatinine including his blood gas parameters normalised. Despite initial improvement, he continued to be inotrope dependent. His intensive care unit monitor (ICU) and chest X-ray are shown. Ultrasound abdomen ruled out significant intra-abdominal pathology except gas shadows. His echocardiogram showed trivial pericardial effusion.
What is next best step to manage this case:
a. Increase Inotropes
b. Increase diuretics
c. Flatus tube colonic decompression
d. Add antibiotics
[11/23, 2:13 PM] +44 Key UK : Needs ionotropes- Dobutamibe, Levosemandan or enoximone.
Pulse pressure is low indicating pump failure. Still needs to rule out Aortic Stenosis. There is no temponade as suggested here.
Practically, needs cardiac output monitoring ( PICCO for example), Angio +/_TOE.
And may end up with mechanical device.
Before embarking on such invasive treatment, his baseline functional status( frailty score), realistic possibility of returning to baseline alobg wirh patient's expectations needs to be explored.
Just because we can do it doesn't mean we should do it.
[11/23, 2:28 PM] SM :
1. Low pulse pressure does not always mean pump failure, it can occur in decreased preload conditions also.
2. Predictive value of low PP decreases when SBP decreases singinifcantly, hence sometime 1/4th of SBP taken as cut off for low PP. Here it’s more than 1/4th of SBP. (Please note the tracing rather the values which is measured as mean)
2. Aortic stenosis was ruled out (He was a on regular follow up)
Yes the patient might need MCS, however the next step is different as u can notice patient’s parameters were improving
I will recommend to see for the tracing rather than the absolute values.
[11/23, 4:17 PM] +44 Key UK :
MAP of 50 with is too low just to rely on intra abdominal pressure. Certainly, in real life scenario most of us won't be comfortable with this MAP in ICU and with only flatus tube, BP is unlikely to improve.
But , I do agree if it's MCQ for an exam.
Thanks
[11/23, 10:41 PM] CME India: What's final answer
Deflate...
[11/23, 10:42 PM] S M : Yes sir.
[11/23, 10:42 PM] S M :
[11/23, 10:43 PM] S M : This was the first reported case of Pulsus paradoxus caused by Intraabdominal hypertension.
[11/23, 10:48 PM] S M : So initial step will be flatus tube decompression followed by assessment for MCS
[11/24, 7:09 AM] Rakesh Biswas: Is there RCT data for the efficacy of this intervention?
Unlikely as the case number is likely to be low?
After reading the entire published article and seeing the pressure trace :
Read the report now and kudos to team Sri Chitra
Loved the powerful simplicity of the pressure trace depicting the fall of CVP, pulse and BP with the presumed rise of abdominal pressure (with some anatomical structural evidence in the form of X-ray)!
Would have made a stronger case for causality perhaps if we had the event timed data (also showcasing multiple other currently unaccounted for events), to demonstrate your causal claim for, to quote from your paper " relationship
of this phenomenon was confirmed when pulsus paradoxus
disappeared after flatus tube decompression of colon and
correction of hypokalaemia (colonoscopic decompression if
no improvement)."
COI statement : I have edited for multiple US and British publishers and one of them (BMJ) used to pay me in pounds for 5 years before I left working with the publishing industry and currently try to utilize tools such as 'case based reasoning' applied to my field of interest aka "Medical cognition"
There's a dense article on case based reasoning here: https://www.ncbi.nlm.
CSI debate thread :
[11/24, 2:52 PM] Shl : Debate Topic: Should cardiologists do General Medicine practice also side by side or sacrifice it?
[11/24, 4:39 PM] GT : 👍🏻Good question.... That's why we need a total revamp of medical education as suggested earlier. See👇🏼
[11/24, 4:40 PM] GT (author of the link below) :
[11/25, 12:38 AM] B N : In USA, most of teachers in cardiology are designated as professor or director of Medicine, Division of Cardiology.
That summerises the issue. Debate is not required.
[11/25, 12:39 AM] H S : Vice versa ??
[11/25, 7:30 AM] RM : There is a crack in everything
That's how the light gets in.
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