Flashcards in Endocarditis Deck (56)
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1
chest pain ddx in IVDU
1. MI
2. PE
3. Aortic dissection
4. Tension pneumothorax
5. Esophageal rupture
6. Injection drug use + fever infection
2
thinking endocarditis you want to order these labs
1. Echo?, CXR, blood cultures, EKG
2. Admit, +/- empiric abx
if you think endocarditis you NEED BLOOD CULTURES
3
malais x2 weeks episodes of L hand clumsiness
with a fever
she looks like she is having a TIA
she has HTN
and work up
1. TB
2. Lacunar infarct
3. Cancer
4. Valvular disease
5. Stroke/TIA
6. Pneumonia
7. Endocarditis
1. EKG, CBC, Blood cultures (for endocarditis) --> get 2 sets and separate by an hour
2. CT to check for bleeds
3. Admit? Empiric abx? (Vancomycin + 3rd gen cephalosporin like ceftriaxone)
blood culture!
4
guy in respiratory distress with underlying HTN
high fever
low pulse ox
diaphoretic crackles and confusion with a weak left arm
PACE MAKER PLACED 2 WEEKS AGO
workup
1. Pneumonia
2. Endocarditis
3. Sepsis
4. PE
1. EKG, blood cultures, LP, CT head, full set of labs, UA, CXR
2. Empiric abx
3. Admit ICU
5
how to think to endocarditis
two requirements
something is wrong withe the lining of your heart
transically bacteremic and you seed the thrombus on the end of the valve
6
b. Oslerian Scheme Clinical Pathophysiology of infectious endocarditis
i. Active endocardial pathology
ii. Predisposing heart dz
iii. Vascular/embolic phenomena
iv. Persistent bacteremia
7
Active endocardial pathology
Vegetation, changing murmur, regurgitant murmur, ECHO findings are now front and center in this diagnosis
When things progress -->Valve destruction, CHF, Myocardial abscess, purulent pericarditis
8
Predisposing heart dz
1. Prosthetic valve, prior IE, congestive heart dz, RHD, etc, MVP w/ regurgitation, PM, AICD
9
Vascular/embolic phenomena
(common signs)
Splenic infarct, etc, CNS infarct,
Osler’s nodes (usually painful see on pads of nails and toes),
Janeway’s lesions (not painful), Splinter hemorrhages under the nails, Roth spots in the eyes, Petechiae
10
iv. Persistent bacteremia
1. Blood cx’s, typical pathogens that causes endocarditis in most causes (usually Staph aureus…others include Strep viridans, enterococcus, fungi)
11
(bug + valve --->typical presentation
i. Staph aureus --> tricuspid valve -->
indolent pulmonary sx
IVDU
landing on the right side of the heart due to lower pressure
don't really need these valves and the manifestations really look like pneumonia
12
Staph aureus --> aortic or mitral valve --->
acute/severe cardia
embolic ssx (brain abscess, AMS at the time of presentation)
1. Acute Bacterial endocarditis
2. Lethal form, very severe
13
Viridens strep., enterococcus --> aortic or mitral valve --->
wimpy pathogen that slowly grows
Classic Subacute endocarditis -->malaise, fever, night sweats
seen with ACD
glomerular nephritis
14
Very sticky and good at causing endocarditis but they don’t cause rapid destruction
Janeway lesions and Osler’s nodes noted
w/ this type of endocarditis
viridens enterococcus
15
d. Current classification (etiology -->likely bugs… -->antibiotic choice
how frequently do you see community acquired
hospital acquired
i. Native valve (85%)
1. Community acquired 55%
2. Hospital acquired 20%
16
bugs for community acquired endocarditis with native valve
a. Staph aureus
b. Strep spp
c. Enterococcus
d. Other
17
Hospital acquired bugs in a native valve
a. Staph aureus (MRSA)
b. Coag neg staph
c. Enterococcus
d. Other
18
IVDU almost always have this bug
a. Almost always Staph aureus (MRSA)
19
prostetic valve bugs
1. Staph aureus
2. Coag neg Staph
20
IE diagnosis: cardinal features
a. Fever -->at the time you come into the ED, 80% of patients are febrile if they don't it might be because they have been popping tylenol
b. Murmur
c. Bacteremia --> get the blood cultures
21
what kind of echo would you do
Can do a transthoracic echo but TEE is really good if you can’t see it on TTE
oscillating mass coming off the leaflet
22
this classification criteria quantifies your diagnostic certainty
e. Duke classification – quantifies your diagnostic certainty
23
Pulmonary emboli occur when you have
R sided endocarditis (tricuspid)
24
underlying valve pathology can be
a. Prosthetic valve
b. Prior IE
c. Congestive heart dz
d. RHD, etc
e. Mitral valve prolapse w/ regurgitation
25
transent bactermia
a. Dental procedure/infection = classic
b. Bad teeth
c. GU procedure/infection
d. IDU
26
how frequently do you have underlying valve pathology
ii. But in 50% of IE,
27
left sided endocarditis makes you more or less sick
more
28
between mitral and aortic valve which one is worse
aortic valve
can cause valve and cardiac failure in hours to days
29
Hx of having had prosthetic valve or congenital heart dz need to
give you huge dose of amoxicillin
30
