Endocarditis, pericarditis, myocarditis, and vasculitis Flashcards
how to measure lactate levels
by taking a blood gas
what are the septic six
give high flow oxygen take blood cultures give IV antibiotics give a fluid challenge - crystalloid measure lactate measure urine output
what does CURB-65 stand for
CURB-65 = Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 years of age and older.
when do you use the CURB-65 score
The CURB-65 calculator can be used in the emergency department setting to risk stratify a patient’s community acquired pneumonia.
risk factors for pneumonia
- Elderly/young children, underlying respiratory disease such as asthma or COPD,
immunosuppression/HIV (every person presenting with pneumonia should have an HIV test), and co-morbidities such as heart disease.
signs and symptoms of typical pneumonia
fever productive cough discoloured sputum SOB pleuritic chest pain high RR low oxygen sats crackles/bronchial breathing on examination
Clinical features of an atypical pneumonia tend to be more constitutional, low grade fever, malaise, headaches, myalgia, cough.
difference between typical and atypical pneumonia
Symptoms of atypical pneumonia tend to be milder and more persistent than those of typical pneumonia, which appear suddenly, and cause a more serious illness. Atypical pneumonia requires different antibiotics than typical pneumonia, which is commonly caused by the bacteria Streptococcus pneumonia.
3 clinical signs of a PE
Shortness of breath. This symptom typically appears suddenly and always gets worse with exertion.
Chest pain. You may feel like you’re having a heart attack. …
Cough. The cough may produce bloody or blood-streaked sputum.
how do we manage pneumonia
Management of pneumonia is supportive with fluids and supplemental oxygen alongside antibiotics. Initially broad-spectrum corresponding to trust guidelines before narrowing once blood cultures/sensitivities are back.
4 steps in the pathophysiology of pneumonia
consolidation
red hepatisation
grey hepatisation
resolution
what is consolidation in pneumonia and when does it occur
Occurs in the first 24 hours
Cellular exudates containing neutrophils, lymphocytes and fibrin replaces the alveolar air
Capillaries in the surrounding alveolar walls become congested
The infection spreads to the hilum and pleura fairly rapidly; pleurisy occurs
red hepatisation and when does it occur
Occurs in the 2-3 days after Consolidation
Lungs become hyperaemic (the increase of blood flow to different tissues in the body); alveolar capillaries are engorged with blood
Fibrinous exudates fill the alveoli
This stage is characterised by presence of many erythrocytes, neutrophils, desquamated epithelial cells, and fibrin within the alveoli
what is grey hepatisation and when does it occur
Occurs in the 2-3 days after Red Hepatisation
This is an avascular stage
The lung appears grey-brown because of fibrinopurulent exudates, disintegration of red cells, and hemosiderin(a protein compound that stores iron in your tissues)
The pressure of exudates in the alveoli causes compression of the capillaries
Leukocytes migrate into the congested alveoli
what is hemiosiderin
a protein compound that stores iron in your tissues
what is resolution
Characterised by resorption and restoration of the pulmonary architecture
A large number of macrophages enter the alveolar spaces
Phagocytosis of the bacteria-laden leucocytes occurs
Consolidation tissue re-aerates and the fluid infiltrate causes sputum
Fibrinous inflammation may extend to and across the pleural space, causing a rub heard by auscultation, and it may lead to resolution or to organisation and pleural adhesions
You are an FY2 working in ED. Paramedics bring in a 36 year old male who was found passed out on a bench. They report he is pyrexial, tachycardic and hypotensive.
The facts - acutely unwell, IVDU patient, septic, raised inflammatory markers, systolic murmur on examination.
Top differential acute bacterial endocarditis.
Other concerns are PE, pneumonia, bacterial cellulitis, compounding by overdose and intoxication, underlying HIV infection.
endocarditis
inflammation of the inner lining of the heart
for endocarditis how many blood cultures should you take
3 cultures from 3 different sites
what should you use to treat infective endocarditis
and for how Long
vancomycin and gentamicin ( trust guidelines) - broad spectrum antibiotics
6 weeks
what can you use to diagnose this
ECHO - diagnostic, either transthoracic(TTE) or transoesophageal(TOE). Transthoracic is more common and more easily accessible, but often a diagnosis of bacterial endocarditis cannot be made or excluded on a TTE, so a transoesphageal is needed to rule it in/out.
what is an echo
An echocardiogram, or “echo”, is a scan used to look at the heart and nearby blood vessels. It’s a type of ultrasound scan
IE typically develops on the valvular surfaces of the heart, which have sustained endothelial damage secondary to turbulent blood flow. As a result, platelets and fibrin adhere to the underlying collagen surface and create a prothrombotic milieu. Bacteraemia leads to colonisation of the thrombus and perpetuates further fibrin deposition and platelet aggregation, which develops into a mature infected vegetation.
Patients who develop native valve endocarditis in the absence of intravenous drug use commonly present with viridans group streptococci, enterococci, or staphylococci, with other pathogens being less frequent. Intravenous drug users often present with right-sided valvular involvement and are more likely to haveS aureus, streptococci, gram-negative bacilli, or polymicrobial infections.
Acute IE is usually associated with what organism
Staphylococcus aureus
what are the causes of IE
Lots of different bacterial causes Strep Viridans Staphylococcus aureus Enterococci Coagulase-negative staphylococci Haemophilus parainfluenzae Fungal (less common)
risk factors for IE
Artificial heart valves previous IE intracardiac devices such as implantable defibrillators chronic rheumatic heart disease age-related degeneration of valves IVDU immunosuppression recent dental procedure
symptoms of acute IE
time period
develops over days to weeks
characterised by fevers, tachycardia, fatigue and progressive damage to cardiac structures
subacute IE symptoms
time period
develops weeks to months
patients will complain of vague constitutional symptoms - low grade fever, weight loss, fatigue , night sweats and appetite loss
what is dukes criteria
The Duke criteria are a set of clinical criteria set forward for the diagnosis of infective endocarditis. For diagnosis the requirement is: 2 major and 1 minor criterion or. 1 major and 3 minor criteria or. 5 minor criteria.
signs on examination of IE
Osler nodes - painful
laneway lesions
splinter haemorrhages
moths sports on fundoscopy
what blood are raised in pericarditis
CRP and troponin
in this heart sound heard like stepping on snow
in pericarditis what would you see on an ECG
wide spread ST elevation and PR depression
what is pericarditis
Inflammation of the pericardium. Over 90% is idiopathic/viral related (coxsackie, EBV, Mumps, CMV, varicella, HIV, Parvovirus) - often patients will have had preceding URTIs.
causes of pericarditis
viral - cosackie
Systemic autoimmune disordersSystemic immune responses (Post-MI, cardiac surgery, radiotherapy)Bacterial/fungal/parasiticNeoplasticUraemicDrug related
who is more likely to get pericarditis
males
aged 20-50
risk factors for pericarditis
cardiac surgery
transmural MI
systemic autoimmune disorders
what is a transmural MI
A transmural myocardial infarction refers to a myocardial infarction that involves the full thickness of the myocardium
symptoms of pericarditis
on auscultation what do you here
sharp pleuritic chest pain radiating pain to trapezius ridges ( phrenic nerve innervates the pericardium and trapezius ridges) relieved when leaning forward worse on lying down not related to exercise not relieved by GTN
pericardial rub on auscultation - like treading on snow
how to manage pericarditis
in community with NSAIDS as well as management of underlying cause
one complication of pericarditis is a large pericardial effusion how do we manage this
drained with pericardiocentesis
myocarditis
Myocarditis is an inflammation of the heart muscle (myocardium).
INFLAMMATION OF THE MYOCARDIUM IN THE ABSENCE OF THE PREDOMINANT ACUTE OR CHRONIC ISCHAEMIA CHARACTERISTIC OF CORONARY ARTERY DISEASE
causes of myocarditis
infectious cause invading the myocardium
local and systemic immunological activation
humoral activating causing local inflammation and anti-heart antibody production and further myonecrosis
causes of myocarditis
viral related - adenovirus
cocaine
SLE and sarcodisosis
who is most likely affected in myocarditis
under 50 years of age
symptoms of myocarditis
chest pain SOB syncope fatigue palpitations can cause arrhymias , cardiac failure and dilated cardiomyopathy
what disease can myocarditis be confused with
acute coronary syndrome - CAG to rule out
ecg changes associated with myocarditis
ECG changes Most common = sinus tachy with non specific ST segment/T wave changes QRS / QT prolongation Diffuse T wave inversion Ventricular arrhythmias AV conduction defects Widespread ST changes - pericarditis
management of myocarditis
Supportive - conventional heart failure therapy to stabilise - ACE-i, diuretics, vasodilators, beta-blocker (once not acutely decompensated), spironolactone.
Treat underlying cause (e.g autoimmune - steroids)
vasculitis
Inflammation of blood vessels
Categorised by size of vessels and ANCA association
Often have generalised symptoms, with a few specific ones for each condition
Many impact the kidneys and lungs
