Acute Mitral Valve Failure

 

An elderly woman woke from sleep with acute breathlessness and wheeze. She had been treated for late-onset asthma by her GP. She had no other previous medical history and was exceptionally active. In the emergency department she received standard treatment for acute severe asthma . A systolic murmur was noted and an echocardiogram requested. After 24 hours of relative stability she experienced a sudden deterioration in her breathing and despite increased therapy for her asthma she had a respiratory arrest.

Following resuscitation and emergency tracheal intubation she was transferred to the ICU. On examination she was peripherally cool. Chest auscultation revealed extensive wheeze and crackles. Investigations revealed a raised troponin I (0.92 ug/L) and raised BNP (530 pmol/L). Her CXR revealed pulmonary oedema and her ECG showed sinus rhythm without overt evidence of ischaemia.

Initial problems included poor oxygenation, oliguria and a low cardiac output state (LiDCO revealed cardiac index of 2.1 l/min/m2). She received norepinephrine (up to 0.6 mcg/kg/min) and dobutamine (up to 40 mcg/kg/min). Levosimendan was introduced to augment her cardiac function as her CI had not achieved to 2.5l/min/m2. Norepinephrine was increased to maintain a MAP over 65mmHg. After levosimendan her urine output, acid-base status and CI were not substantially improved. The dobutamine had been stopped and she remained on norepinephrine.

An echocardiogram revealed hyperdynamic LV and RV and mitral regurgitation, which was initially assessed as being moderate in severity. Cardiac surgical opinion was that the risk of mitral valve surgery was unacceptably high.

Over the following few days she had problems with recurrent compromising atrial fibrillation and was treated with varying degrees of success with a variety of measures including DC cardioversion, amiodarone, metoprolol, digoxin and verapamil. Diuresis was obtained with a frusemide infusion and ramipril was introduced. Her CXR appearances improved and ventilation became easier.

On the 3rd day a trans-oesphageal echocardiogram confirmed severe mitral regurgitation (MR) with prolapse of the posterior mitral valve (MV) leaflet due to a ruptured chordae tendinae. There was resultant left atrial enlargement and pulmonary hypertension with an estimated PA systolic pressure of 60-70mmHg. Within a week she was weaned from ventilatory support and recovered sufficiently to mobilise independently prior to discharge home.Read More »

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Dexamethasone in Bacterial Meningitis

Dexamethasone in Bacterial Meningitis

A previously healthy 25 year old female was admitted with low GCS and a fever. She had a 24 history of viral symptoms including sore throat and a headache. On admission she had a GCS of 3, temperature of 38.9°C and raised inflammatory markers. She was intubated but did not require vasopressor support. A CT brain showed diffuse cerebral swelling, effacement of the sulci, sylvian fissures, basal cisterns and 3rd/4th ventricles, and early cerebellar tonsillar herniation. Lumbar puncture was not performed due to CT appearances. She was commenced on intravenous (IV) ceftriaxone 2g twice daily, IV acyclovir 800mg three times daily, and IV dexamethasone 10mg four times daily. Unfortunately, her pupils remained fixed and dilated on sedation hold 36 hours later, and she was making no respiratory efforts. She subsequently became a DBD organ donor.

What is the evidence for dexamethasone in bacterial meningitis?

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Necrotising Fasciitis - Advances in diagnosis and management

Necrotising Fasciitis – Advances in diagnosis and management

A 40 year old man underwent a minor elective day case lower limb soft tissue operation. 72 hrs later he began to feel unwell and developed fevers and rigors. He was seen first thing in the morning with increasing pain and inflammation extending up from the foot to the knee. Intravenous antibiotics were started on admission. He was in theatre having a debridement by late morning, by which time the inflammation had spread to the inner thigh. He was in profound septic shock with disseminated intravascular coagulopathy. During the debridement, it was noted that the inflammation had spread to his pelvis. He had a laparotomy and it was determined that the resection he would require was unsurvivable. Treatment was withdrawn and he died on the operating table.

How is necrotising fasciitis diagnosed and how is it managed?

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