endocarditis, pericarditis, tamponade Flashcards
1
Q
aortic valve endocarditis
A
- most common valve involved
- can have aortic abscess which would indicate worse prognosis
2
Q
tricuspid valve endocarditis
A
- most common in IVDU
- septic PE also assoc
3
Q
bicuspid valve endocarditis
A
- not as common
- can lead to aortic valve involvement
4
Q
risk factors for endocarditis
A
- age > 60
- underlying valve disease
- male sex
- IVDU
- pior valve surgery
- poor dentition
- prior hx of IE
- intravascular device or cardiac implantable device
- chronic hemodyalisis
- HIV infection
5
Q
what pts should get abx prophylaxis for endocarditis
A
- prosthetic valves and/or repairs
- hx of IE
- unrepaired cyanotic congenital heart disease
- repair of congenital heart disease with residual shunt or regurg
- valve regurg d/t structurally abnormal valve in transplant heart
6
Q
what procedures do you give prophylactic abx for endocarditis?
A
- dental work
- respiratory tract procedures
- skin and soft tissue procedures
- cardiac surgery with prosthetic material
7
Q
what abx do you use for endocarditis prophylaxis
A
- po amoxicillin
- cephalexin, clindamycin, or macrolides if allergic to PCN
- given as 1 time dose 1 hour prior to surgery
8
Q
most common bacterial cause of endocarditis in native valves
A
- staph aureus- usually acutely ill
- viridans group streptococci
- enterococci
- coag neg staph
9
Q
most common bacterial cause of endocarditis in prosthetic valves
A
- s aureus within 2 mo of surgery
- strep after 2 mo
10
Q
most common bacterial cause of endocarditis in IVDU
A
- MRSA
11
Q
si/sx of endocarditis
A
- fever
- new onset murmur
- janeway lesions
- osler nodes
- roth spots
12
Q
janeway lesions
A
- nontender erythematous macules on palms and soles
- indicates endocarditis
13
Q
osler nodes
A
- tender subq nodules on pads of fingers and toes
- indicates endocarditis
14
Q
roth spots
A
- exudative erythematous hemorrhagic lesions of retina with pale center
- indicates endocarditis
15
Q
complications of endocarditis
A
- most related to septic emboli
- valve insufficiency and HF
- neurologic complications i.e. embolic stroke
- septic emboli- kidneys, spleen
- PE associated with tricuspid valve endocarditis
- metastatic infections
- systemic immune reactions
16
Q
diagnosis of endocarditis
A
- check CBC with diff, chem 10, LFTs, UA
- EKG- may show conduction abnormalities
- blood cultures
- echo- gold stnd
- TTE first but most pts also need TEE
- ct scan for spetic emboli
- valve culture in OR
17
Q
what is the duke criteria used for?
A
- stratifies pt risk for endocarditis
- definite IE
- possible IE
- rejected IE
- used only for left sided native valve endocarditis
18
Q
definite IE
A
- 2 major
- 1 major and 3 minor
- 5 minor
19
Q
possible IE
A
- 1 major and 1 minor
- 3 minor
20
Q
rejected IE
A
- firm alternate dx
- resolution of sx after < 4 days abx
- no pathologic evidence of IE found in surgery or autopsy
- clinical criteria for possible or definite not met
21
Q
major duke criteria
A
- 2 pos blood cultures or persistent bacteremia
- endocardial involvement on echo
- new regurg murmur
22
Q
minor duke criteria
A
- presence of predisposing conditions- IVDU or prior valve issues
- fever > 38
- vascular phenomenon
- immunologic phenomenon
- pos blood culture not meeting major criteria
- serologic evidence of acute infection
23
Q
medical management of endocarditis
A
- get blood cultures before abx
- empiric abx therapy
- IV abx 4-6 weeks via PICC line
- oral suppression for recurrent endocarditis or risk factors for recurrence
- most cases medically managed
24
Q
surgical management of endocarditis
A
- infectious cause must be removed unless hemodyn unstable
- acute HF unresponsive to tx
- infection unresponsive to medical tx 7-10 days
- recurrent endocarditis
- continued embolization despite medical mgmt
25
normal pericardial fluid
- 15-50 ml
| - made up of mostly plasma
26
acute pericarditis
- less than 2 weeks
| - often viral
27
noninfectious causes of acute peridcarditis
- metastasis, radiation
- autoimmune disorders
- metabolic disorders
- trauma
- drugs- penicillins
- idiopathic
- dressler's syndrome
28
what is dressler's syndrome
- post MI -> irritation of pericaridum
29
subacute pericarditis
- greater than 2 weeks
30
common causes of subacute pericarditis
- Tb
- dressler's syndrome
- radiation
31
clinical presentation of pericarditis
- pleuritic chest pain
- dyspnea
- recent illness
- know carcinoma, autoimmune disorders, recent MI, or cardiac surgery
32
PE findings for pericarditis
- pericardial friction rub*
- fever, malaise
- if bacterial pt will look very ill
- neoplastic cause is usually painless and presents with hemodyn instability
33
EKG changes associated with pericarditis
- diffuse ST elevations
34
treatment for pericarditis
- ASA 1-2 weeks
- NSAIDs 2-3 weeks, usually indomethacin or ibuprofen
- if resistant or recurrent tx with steroid
- Dressler's syndrome- colchicine X 3 months +/- NSAIDs
- mostly treated as outpatient
35
admission for pericarditis
- fever > 100.4
- subacute course
- tamponade
- large pericardial effusion
- immunosuppressed
- anticoagulation
- acute trauma
- fail to improve with OP tx
- elevated cardiac enzymes
36
complications of pericarditis
- constrictive pericarditis
| - tamponade
37
constrictive pericarditis
- inflammation -> chronic thickened, fibrotic adherent pericardium
- restricts diastolic filling
- chronically elevated venous pressures
- poor prognosis
38
causes of constrictive pericarditis
- radiation in thorax
- cardiac surgery
- viral pericarditis
- Tb
- histoplasmosis
39
clinical presentation of constrictive pericarditis
- slow and progressive onset dyspnea, fatigue, weakness
- chronic edema, ascites
- prior pericarditis, MI, radiation, or cardiac surgery
40
PE findings of constrictive pericarditis
- elevated JVD
- kussmaul sign
- pericardial knock
- hepatic congestion
- afib
41
diagnostic tests for constrictive pericarditis
- CXR may show pericardial calcifications
- thickening > 4 mm on CT or MRI
- echo- thickened pericardium and septal bounce
- cardiac cath
42
treatment for constrictive pericarditis
- diuretics
- refer to cardiology
- pericardiectomy
43
pericardial effusion
- accumulation of fluid > 15-50 mL
44
clinical presentation of pericardial effusion
- may be asymptomatic esp if chronic
- chest pain, dyspnea, cough
- recent pericarditis, carcinoma, cardiac surgery, MI or illness
- pericardial friction rub*
- muffled heart sounds*
45
diagnostic tests for pericardial effusion
- CXR may show widened mediastinum if large effusion
- EKG- low voltage or electrical alternans
- echo- gold std
46
treatment of pericardial effusions
- if small can observe with serial echos
- if mod-lg effusion do pericardiocentesis, pericardial drain placement
- recurrent- pericardial window
47
tamponade
- accumulation of fluid in pericardial space that causes significant change in hemodynamics
- restricts venous return and ventricular filling
- complication of pericardial effusions based on how fast effusion accumulates
48
acute tamponade presentation
- life threatening*
- death
- cardiogenic shock, hypotension, tacycardia
- dyspnea, tachypnea
- chest pain
- elevated JVD
- muted heart sounds
- decreased urine output and end organ perfusion
49
beck's triad of tamponade
- hypotension
- elevated JVD
- muffled heart sounds
50
pulsus paradoxus
- occurs in tamponade
| - greater than 10 mm decline in systolic pressure during inspiration d/t impaired LV filling
51
diagnosis of tamponade
- echo
| - any RV compression is considered tamponade
52
treatment of tamponade
- emergent pericardiocentesis
- if s/p cardiac surgery then reopen sternotomy
- if trauma or surgery related pericardial drain is sometimes left in place
