Endocarditis Flashcards Preview

Emergency Medicine > Endocarditis > Flashcards

Flashcards in Endocarditis Deck (56)
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

Native valve, no IDU

anbx

i. Vancomycin + ceftriaxone

31

Native valve, IDU anbx

i. Vancomycin

32

Prosthetic valve, PM, AICD

i. Vancomycin + gentamycin + rifampin

33

surgical treatment is needed in how many cases

what are the indications

50%
i. Destroyed valve --> going into hear failure
ii. Intracardiac valve abscess

34

when do you get prophylactic antibiotics

congenital heart dz
prosthetic ht valve
prior IE
cardiac transplant

and dental procedure

35

38 yo man presents to an ambulatory care clinic c/o CP. Pain presents x 24 hours. Severe, sharp, increases with inspiration. Radiates to bilateral trapezius area. + subjective SOB, no n/v/d. No CAD hx.

RoS: cough, tactile fevers, chills

PE
low grade fever with boderline tachycardia

this guys is a mover

muscle strain
pleurisy
pneumonia,
MI
tension pneumothorax
pericarditis
PE

36

the schemes of pericarditis

smooth surface on the parietal and visceral side

these things are rubbing and are really prone to inflammation

think of your knees

37

what leads to pericarditis

i. Viral/idiopathic
ii. Infection/purulent
iii. Rheumatologic/CA/post-cardiac injury
iv. Uremic


lupus is one of those pneumatological diseases

38

common viral courses of pericarditis

Coxsackieviruses virus

39

bacterial and infectious causes

s aureus
pneumococcus
TB
fungal

40

slow fluid accumulation with pericarditis

myocarditis

this is seen with arrhythmia
heart failure

41

greater than 2cm of fluid prone to cause

tamponade from effusion

this is seen with cancer

42

1. Myo-pericarditis pathogens -->

Viral (coxsackie), bacterial/purulent

43

myocarditis presentation

arrhythmias, heart failure, elevated cardiac enzymes

44

sxs with pericarditis as far as characteristic of pain

better when you lean forward worse when you lean back

pain radiating to the traps

45

two big reasons you get from tamponade

3. Tamponade from trauma usually or mets

46

pericarditis findings

Chest pain – pleuritic, positional - worse when lying down, relief with leaning forward

Pericardial friction rub

along with the EKG

47

EKG findings for pericarditis

widespread ST elevation shaped like a saddle or smile face

PR segment depression

48

(knuckle sign)

PR segment elevation in aVR

49

Stages of pericarditis -->done over days and weeks

a. Stage 1- come in with pain and you see the addle
b. Stage 2
c. Stage 3 – inverted T wave (1-2 weeks)
d. Stage 4 – back to normal

50

cardinal sign of tamponade

a. Muffled heart sounds
b. JVD
c. Tachycardia
d. Hypotension
e. Pulsus paradoxus

51

Pulsus paradoxus

abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration

i. Drop in SBP exceeding 10mmHg during inspiration

52

echo findings with tamponade

i. Equalization of pressures
ii. RV impinging on LV during diastole

1-2 cm of fluid

53

Idiopathic: pericarditis mangement

NSAID + colchicine (prednisone if cannot take NSAID)

54

Febrile/toxic tx

: admit/consult, blood cx, dx’ic pericardiocentesis (ECHO-guided)

55

Renal failure tx

– emergent hemodialysis

56

tamponade tx

– volume loading, emergent pericardiocentesis