The second-best part of last week’s lecture was the M.S. v A.C. throwdown.
The best part of the lecture was the smart comments from all the residents, esp the PGY-4s.
The treatment of endocarditis is sometimes surgery.
Indications include heart failure, uncontrolled infection, perivalvular infection, prosthesis, weird organisms, embolism. Our patient had multiple indications.
Osmolar gap causes – toxic alcohols, not-so-toxic alcohols, lactate. Try to memorize the formula in case the computers go down.
We’re not here to follow orders blindly, imho.
The patient was hypoglycemic from a hypermetabolic cause – sepsis.
RR = 30 + sat of 100 = suspect metabolic acidosis. (10 points to House Tarr).
Sometimes, it’s not so important to treat vtach. VT does not always cause hemodynamic compromise (aka stable vtach). Often, you have enough time to call a lifeline. We never determined whether the rhythm was VT or not. My guess was yes. My second guess would be aflutter with aberrancy.
Wide-complex rhythm in esrd pt = suspect K, though this pt’s K was normal. (10 points to House Chinn).
It’s extremely unusual to have a huge anterior wall MI without chest pain (maybe never) if the patient is conscious. (10 points to House Breinager).
Residency training is often about pattern recognition. We see big MIs and bad CHF all the time, but they’re never acidotic (well almost never). So chances are, there’s something else going on.
There is no great treatment for cardiogenic shock. If there’s an acute MI, send pt to PCI or CABG. Otherwise, I generally use dobutamine, it’s what I grew up with. The past recommendation of levo doesn’t make sense physiologically.
Begging works.
You only need one additional tube of blood to work up an anion gap. If you already sent a lactate then you don’t need any additional blood at all. An urine is helpful and potentially diagnostic at times.
Twenty years ago, there was no such thing as an MRSA infection.
Follow up your patients.
https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2016/01/08/15/13/timing-of-surgery-in-infective-endocarditis
https://heart.bmj.com/content/90/6/618