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
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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
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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
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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
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b. Oslerian Scheme Clinical Pathophysiology of infectious endocarditis
i. Active endocardial pathology
ii. Predisposing heart dz
iii. Vascular/embolic phenomena
iv. Persistent bacteremia
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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
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Predisposing heart dz
1. Prosthetic valve, prior IE, congestive heart dz, RHD, etc, MVP w/ regurgitation, PM, AICD
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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
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iv. Persistent bacteremia
1. Blood cx’s, typical pathogens that causes endocarditis in most causes (usually Staph aureus…others include Strep viridans, enterococcus, fungi)
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(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
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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
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Viridens strep., enterococcus --> aortic or mitral valve --->
wimpy pathogen that slowly grows
Classic Subacute endocarditis -->malaise, fever, night sweats
seen with ACD
glomerular nephritis
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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
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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%
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bugs for community acquired endocarditis with native valve
a. Staph aureus
b. Strep spp
c. Enterococcus
d. Other
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Hospital acquired bugs in a native valve
a. Staph aureus (MRSA)
b. Coag neg staph
c. Enterococcus
d. Other
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IVDU almost always have this bug
a. Almost always Staph aureus (MRSA)
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prostetic valve bugs
1. Staph aureus
2. Coag neg Staph
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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
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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
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this classification criteria quantifies your diagnostic certainty
e. Duke classification – quantifies your diagnostic certainty
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Pulmonary emboli occur when you have
R sided endocarditis (tricuspid)
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underlying valve pathology can be
a. Prosthetic valve
b. Prior IE
c. Congestive heart dz
d. RHD, etc
e. Mitral valve prolapse w/ regurgitation
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transent bactermia
a. Dental procedure/infection = classic
b. Bad teeth
c. GU procedure/infection
d. IDU
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how frequently do you have underlying valve pathology
ii. But in 50% of IE,
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left sided endocarditis makes you more or less sick
more
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between mitral and aortic valve which one is worse
aortic valve
can cause valve and cardiac failure in hours to days
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Hx of having had prosthetic valve or congenital heart dz need to
give you huge dose of amoxicillin
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Native valve, no IDU
anbx
i. Vancomycin + ceftriaxone
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Native valve, IDU anbx
i. Vancomycin
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Prosthetic valve, PM, AICD
i. Vancomycin + gentamycin + rifampin
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surgical treatment is needed in how many cases
what are the indications
50%
i. Destroyed valve --> going into hear failure
ii. Intracardiac valve abscess
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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
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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
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myocarditis presentation
arrhythmias, heart failure, elevated cardiac enzymes
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sxs with pericarditis as far as characteristic of pain
better when you lean forward worse when you lean back
pain radiating to the traps
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two big reasons you get from tamponade
3. Tamponade from trauma usually or mets
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pericarditis findings
Chest pain – pleuritic, positional - worse when lying down, relief with leaning forward
Pericardial friction rub
along with the EKG
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EKG findings for pericarditis
widespread ST elevation shaped like a saddle or smile face
PR segment depression
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(knuckle sign)
PR segment elevation in aVR
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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
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cardinal sign of tamponade
a. Muffled heart sounds
b. JVD
c. Tachycardia
d. Hypotension
e. Pulsus paradoxus
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Pulsus paradoxus
abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration
i. Drop in SBP exceeding 10mmHg during inspiration
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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)
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Renal failure tx
– emergent hemodialysis
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