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Emergency Medicine > Endocarditis > Flashcards

Endocarditis Flashcards

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1
Q

chest pain ddx in IVDU

A
  1. MI
  2. PE
  3. Aortic dissection
  4. Tension pneumothorax
  5. Esophageal rupture
  6. Injection drug use + fever  infection
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2
Q

thinking endocarditis you want to order these labs

A
  1. Echo?, CXR, blood cultures, EKG
  2. Admit, +/- empiric abx

if you think endocarditis you NEED BLOOD CULTURES

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3
Q

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

A
  1. TB
  2. Lacunar infarct
  3. Cancer
  4. Valvular disease
  5. Stroke/TIA
  6. Pneumonia
  7. Endocarditis
  8. EKG, CBC, Blood cultures (for endocarditis) –> get 2 sets and separate by an hour
  9. CT to check for bleeds
  10. Admit? Empiric abx? (Vancomycin + 3rd gen cephalosporin like ceftriaxone)

blood culture!

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4
Q

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

A
  1. Pneumonia
  2. Endocarditis
  3. Sepsis
  4. PE
  5. EKG, blood cultures, LP, CT head, full set of labs, UA, CXR
  6. Empiric abx
  7. Admit ICU
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5
Q

how to think to endocarditis

two requirements

A

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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6
Q

b. Oslerian Scheme Clinical Pathophysiology of infectious endocarditis

A

i. Active endocardial pathology
ii. Predisposing heart dz
iii. Vascular/embolic phenomena
iv. Persistent bacteremia

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7
Q

Active endocardial pathology

A

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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8
Q

Predisposing heart dz

A
  1. Prosthetic valve, prior IE, congestive heart dz, RHD, etc, MVP w/ regurgitation, PM, AICD
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9
Q

Vascular/embolic phenomena

common signs

A

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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10
Q

iv. Persistent bacteremia

A
  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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11
Q

(bug + valve —>typical presentation

i. Staph aureus –> tricuspid valve –>

A

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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12
Q

Staph aureus –> aortic or mitral valve —>

A

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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13
Q

Viridens strep., enterococcus –> aortic or mitral valve —>

A

wimpy pathogen that slowly grows

Classic Subacute endocarditis –>malaise, fever, night sweats

seen with ACD
glomerular nephritis

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14
Q

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

A

viridens enterococcus

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15
Q

d. Current classification (etiology –>likely bugs… –>antibiotic choice

how frequently do you see community acquired
hospital acquired

A

i. Native valve (85%)
1. Community acquired 55%
2. Hospital acquired 20%

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16
Q

bugs for community acquired endocarditis with native valve

A

a. Staph aureus
b. Strep spp
c. Enterococcus
d. Other

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17
Q

Hospital acquired bugs in a native valve

A

a. Staph aureus (MRSA)
b. Coag neg staph
c. Enterococcus
d. Other

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18
Q

IVDU almost always have this bug

A

a. Almost always Staph aureus (MRSA)

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19
Q

prostetic valve bugs

A
  1. Staph aureus

2. Coag neg Staph

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20
Q

IE diagnosis: cardinal features

A

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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21
Q

what kind of echo would you do

A

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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22
Q

this classification criteria quantifies your diagnostic certainty

A

e. Duke classification – quantifies your diagnostic certainty

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23
Q

Pulmonary emboli occur when you have

A

R sided endocarditis (tricuspid)

24
Q

underlying valve pathology can be

A

a. Prosthetic valve
b. Prior IE
c. Congestive heart dz
d. RHD, etc
e. Mitral valve prolapse w/ regurgitation

25
Q

transent bactermia

A

a. Dental procedure/infection = classic
b. Bad teeth
c. GU procedure/infection
d. IDU

26
Q

how frequently do you have underlying valve pathology

A

ii. But in 50% of IE,

27
Q

left sided endocarditis makes you more or less sick

A

more

28
Q

between mitral and aortic valve which one is worse

A

aortic valve

can cause valve and cardiac failure in hours to days

29
Q

Hx of having had prosthetic valve or congenital heart dz need to

A

give you huge dose of amoxicillin

30
Q

Native valve, no IDU

anbx

A

i. Vancomycin + ceftriaxone

31
Q

Native valve, IDU anbx

A

i. Vancomycin

32
Q

Prosthetic valve, PM, AICD

A

i. Vancomycin + gentamycin + rifampin

33
Q

surgical treatment is needed in how many cases

what are the indications

A

50%

i. Destroyed valve –> going into hear failure
ii. Intracardiac valve abscess

34
Q

when do you get prophylactic antibiotics

A

congenital heart dz
prosthetic ht valve
prior IE
cardiac transplant

and dental procedure

35
Q

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

A

this guys is a mover

muscle strain
pleurisy
pneumonia, 
MI
tension pneumothorax
pericarditis  
PE
36
Q

the schemes of pericarditis

A

smooth surface on the parietal and visceral side

these things are rubbing and are really prone to inflammation

think of your knees

37
Q

what leads to pericarditis

A

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

lupus is one of those pneumatological diseases

38
Q

common viral courses of pericarditis

A

Coxsackieviruses virus

39
Q

bacterial and infectious causes

A

s aureus
pneumococcus
TB
fungal

40
Q

slow fluid accumulation with pericarditis

A

myocarditis

this is seen with arrhythmia
heart failure

41
Q

greater than 2cm of fluid prone to cause

A

tamponade from effusion

this is seen with cancer

42
Q
  1. Myo-pericarditis pathogens –>
A

Viral (coxsackie), bacterial/purulent

43
Q

myocarditis presentation

A

arrhythmias, heart failure, elevated cardiac enzymes

44
Q

sxs with pericarditis as far as characteristic of pain

A

better when you lean forward worse when you lean back

pain radiating to the traps

45
Q

two big reasons you get from tamponade

A
  1. Tamponade from trauma usually or mets
46
Q

pericarditis findings

A

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

Pericardial friction rub

along with the EKG

47
Q

EKG findings for pericarditis

A

widespread ST elevation shaped like a saddle or smile face

PR segment depression

48
Q

(knuckle sign)

A

PR segment elevation in aVR

49
Q

Stages of pericarditis –>done over days and weeks

A

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
Q

cardinal sign of tamponade

A

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

51
Q

Pulsus paradoxus

A

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

i. Drop in SBP exceeding 10mmHg during inspiration

52
Q

echo findings with tamponade

A

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

1-2 cm of fluid

53
Q

Idiopathic: pericarditis mangement

A

NSAID + colchicine (prednisone if cannot take NSAID)

54
Q

Febrile/toxic tx

A

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

55
Q

Renal failure tx

A

– emergent hemodialysis

56
Q

tamponade tx

A

– volume loading, emergent pericardiocentesis

Emergency Medicine (28 decks)

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