AM report pearls 4/5: management of shock in patients with VSD / fever pearls!

ASD and VSD (complete or partial) are the most common cardiac manifestations of Down’s syndrome! Pearls from YY in this previous blog post.

VSD is an acyanotic heart defect until you develop Eisenmengers: as long as the shunt is still left to right, VSD is acyanotic (deoxygenated blood from the RV is not going into the LV before L-sided pressures are higher than the R). If a VSD is uncorrected for a long period of time, right-sided pressures become greater than left, leading to Eisenmengers (right to left shunt) leading to deoxygenated blood going into the LV and thus cyanosis.

Management of shock in patients with VSD/left to right shunt: the key is to maintain left-sided pressures higher than right-sided pressures to maintain left to right shunt (i.e. prevent it from going right to left leading to deoxygenated blood going into the systemic circulation). Thus, it is critical to maintain high systemic pressure (SVR) with pressors and low pulmonary/intrathoracic pressure (use low PEEP).


Fever pearls: Not to be memorized, but thank you to Kavita and Sam for sharing a short list of ddx based on height of fever!! (per Harry Lampiris)

Fever <102oF (<38.9oC) Fever 102-106oF Fever >106oF (>41oC)
·         acute cholecystitis

·         acute MI

·         phlebitis

·         PE/infarct

·         pancreatitis

·         uncomplicated wound infection

·         GI bleed

·         catheter associated bacteruria

·         cholangitis

·         pericarditis

·         suppurative thrombophlebitis

·         pancreatic abscess/infected pseudocyst

·         nonhepatitis viral/liver disease (EBV, drug)

·         severe/complicated wound infection

·         bowel infarct

·         pyelo

Typically not infectious!!

·         Drug fever

·         central fever (neoplastic, trauma, infection)

·         heat stroke

·         HIV

·         malignant hyperthermia

·         NMS


Lastly, a review of FUO, pancytopenia, ferritinemia, AND HLH diagnostic criteria from an old AM report pearls here (so relevant! :)).




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