Murmurs and CPC 6 shock Flashcards
Questions for a heart murmur history - PMx, recent Hx, Sx, Fx.
PMx
Do they know of a murmur?
Any history of hypertension, ischaemic heart disease, other cardiac problems.
Rheumatic fever?
Look at them: do they have Down’s or Turner’s?
Recent Hx
Have they had… malaise, fever, night sweats, weight loss (endocarditis).
Sx
How much do they drink (alcoholoic dilated cardiomyopathy)?
Do they use drugs/ long standing IV/ recent dental work (endocarditis)?
Fx
Marfan’s?
What murmur does Marfan’s cause?
Aortic regurg.
What murmur does rheumatic fever cause?
Any valves affected: initially incompetance, stenosis years later.
What murmur does alcoholism cause and how?
Causes dialted cardiomyopathy, leading to aortic or mitral regurg.
Which murmur is associated with a wide pulse pressure?
Aortic regurg.
Which murmur is associated with a narrow pulse pressure?
Aortic stenosis or mitral stenosis.
Which murmur is associated with a tapping apex beat?
Mitral stenosis
Which murmur is associated with a heaving apex beat?
Aortic stenosis
Which murmur is associated with a thrusting apex beat?
Mitral regurg.
Which murmur is associated with right ventricular heaves?
Mitral stenosis (as RV heaves are associated with pul. hypertension)
Which murmur is associated with a collapsing pulse?
Aortic regurg.
Which murmur is associated with a slow rising pulse?
Aortic stenosis.
Symptoms of infective endocarditis
Fever, previous infections, previous valvular disease/replacement.
Also: night sweats, general malaise, weight loss, joint pain, tachycardia, pyrexia, embolisms elsewhere.
Osler’s nodes, Janeway lesions, Rott’s spots, splinter haemorrhages.
Which patients are prone to infective endocarditis
Pts with valvular replacement and/or immunosuppression.
Organisms causing infective endocarditis
Strep viridans, staph, enterococci, chlamydia
Investigations for suspected infective endocarditis
FBC, U&Es Blood cultures, 1 before Abx. ECG for associated MIs. CXR for heart failure Transthoracic echo for valvular changes Urinalysis.
Treatment for infective endocarditis
Several weeks of Abx: benzopenicillin, vancomycin, gentamycin.
Types of synthetic heart valve
Common: bileaflet, tilting disc
Rarer: ball and cage, trileaflet.
What is shock?
A state of cardiovascular collapse leading to impaired tissue perfusion and cellular hypoxia.
What are the symptoms of shock?
Altered conscious state Restless or irritable Excessive thirst and tachycardic with weak pulse. Pale or bluish skin. Tachypnoeic and hypoxic. Hypovolaemic Nausea and or vomiting.
Causes of shock
Reduction in cardiac output (pump failure or obstruction)
Reduction in circulating volume (hypovolaemic or distributive)
Causes of shock: pump failure
Myocardial damage
Ventricular arrhythmias
Myocarditis
What is an embolus
A detached intravascular solid, liquid or gaseous mass that is carried by the blood to a site distant from its point of origin.
Where do fat emboli come from?
Long bone fractures, orthopaedic interventions, soft tissue trauma and burns.
Where do air emboli come from?
Obstetric procedures, chest wall trauma, decompression sickness and iatrogenesis.
What causes myocarditis?
Infections, autoimmune and idiopathic causes
What are the infective causes of myocarditis?
Viral origin, usually coxsackie virus leading to development of anti-myosin and anti-troponin I due to cross-reactivity.
Eosinophilic myocarditis includes…
hypersensitivity myocarditis,
hypereosiniophilic syndromes and parasitic infections.
Granulomatous myocarditis can be caused by
Sarcoidosis
Granulomatous infections
Hypersensitivity reactions.
Giant cell myocarditis is associated with…
Thymoma, lymphoma, SLE, thyroiditis, dermatomyositis.
Causes of cardiac shock: obstructive
Compression - cardiac tamponade due to ruptured infarct, aortic dissection or penetrating trauma.
Tension pneumothorax
Outflow obstruction e.g. pulmonary embolus.
Causes of hypovolaemic shock
Haemorrhage, severe dehydration (vomiting, diarrhoea, electrolyte imbalance), burns and trauma.
Causes of distributive shock
Sepsis
Anaphylaxis
Neurogenic
Acute adrenal insufficiency.
Aetiology of gram -ive shock
Due to LPS. Activates cytokine cascade leading to systemic vasodilatation, diminished myocardial contractility, endothelial activation,
leucocyte adhesion and acute respiratory distress syndrome. Activation of coagulation and DIC.
Symptoms of severe shock
Organ dysfunction
• lactic acidosis
• oliguria
or • an acute alteration in mental status
What is SIRS?
response to a variety of processes. Manifested by ≥2 of the following conditions: • Temperature > 38°C or 90 beats/min • Respiratory rate > 20 breaths/min • Acutely altered mental state • Glucose >7.7mmol/L (if not diabetic) • WBC count >12,000/mm3 ,
What are the sepsis 6?
Give 3 - oxygen, Abx within 1 hr, IV fluid up to 30 ml/kg in divided boluses.
Take 3 - blood cultures, serum lactate and FBC, urine output measurement.
Results of investigations for severe sepsis.
sBP 2 mmol/l Urine output 1.5 or aPTT>60s Bilirubin > 34 umol/l O2 keep SpO2 above 90%. Platelets 177 umol/l
Symptoms of anaphylactic shock.
Often febrile if severe.
Any skin rash (e.g. cutaneous vesicles?), swelling of
tongue/throat, stridor, wheezes or hoarseness,
diarrhoea, cramps or vomiting, pelvic pain, cerebral
symptoms?
Tachy OR bradycardic
Causes of anaphylactic shock.
Many, including
Drugs – antibiotic, neuromuscular blockers, aspirin, NSAIDs, IV contrast media, opioid analgesics.
Food
What microbiology samples can you take in anaphylactic shock?
For cough/sputum/chest pain take sputum/BAL
Dysuria, urinary frequency take urine sample, GU swabs.
For abdominal pain, diarrhoea or distension take stool sample
For headache with neck stiffness take CSF
For line infection take blood cultures
For cellulitis or wound infection take wound swab
For septic arthritis do joint aspirate
For endocarditis take multiple blood cultures.
If you suspect anaphylactic shock, what test do you do at 1-4hr, and at 24 hr?
Serum tryptase test. Indicates mast cell degranulation, whether IgE or non-IgE mediated. Anaphylactic or anaphylactoid reactions. Blood sample both at ONSET at 1-4hr and at 24 hr.
What is SJS and TEN?
Rare, acute and potentially fatal skin reactionleading to sheet-like skin and mucosal loss.
Usually response to medications. Often drugs with long half-lives.
Symptoms of SJS
Painful red rash starting on trunk. Macules, targets or blisters. Blisters merge to form sheets of skin detachment. Positive nikolsky sign
At least 2 mucosal surfaces are also
involved. No actual blisters.
What is the Nikolsky sign for SJS?
If it is positive, where skin is red blisters form on gentle rub.
Aetiology of neurogenic shock.
Sudden loss of signals that maintain the normal muscle tone in blood vessel walls. Vessels dilate leading to pooling blood and drop in blood pressure.
Complications of neurogenic shock
Can lead to spinal cord or brain lesions. Regional anaesthesia.
Initial phase of shock (1)
Hypoperfusion –> hypoxia –> lactic acidosis.
Compensated phase of shock (2)
Intrinsic regulatory mechanisms. Hyperventilation, increasing BP, vasoconstriction. Fluid retenition via ADH action in kidneys. Blood diverted to heart, lungs and brain.
Uncompensated phase of shock (3)
Compromised microvasculature, failing organ function, hypotensive. Build up of intracellular Na+ and leakage of K+
Irreversible phase of shock (4)
Damage to key organs. E.g. edema and haemorrhage.
Heart – reduced myocardial contractility, negative inotropic effects,
Lungs – oedema leads to ARDS
Liver – loss of function. Hypoglycaemia and hypoalbuminaemia.
Gut – oedema, malabsorption.
vasodilation and loss of systemic vascular resistance.
Initial treatment for shock
o Even before working out cause, secure a drip and give O2.
o Take careful history
What heart defects does Down’s syndrome cause?
Endocardial cushion defects.
What heart defects does Williams syndrome cause?
Supravalvular aortic stenosis.
What are the Marfanoid features?
high arched palate, long arm span, abnormally flexible joints, scoliosis, sternum defects (indented or protuberant)
What does a high volume pulse denote?
Hyperdynamic circulatory states like anaemia and thyrotoxicosis.
What does a low volume pulse denote?
Aortic stenosis.
What does a large V wave in the JVP denote?
Tricuspid regurgitation.
What does the following heart murmur denote: Loud P2
pulmonary hypertension.
What does the following heart murmur denote: wide split A2 P2
Prolonged right ventricular systole due to pulmonary hypertension, pulmonary stenosis or an atrial septal defect.
What does the following heart murmur denote: wide fixed split A2 P2
Atrial septal defect.
Reversed split P2 A2
Prolonged left ventricular systole (outflow obstruction, aortic stenosis, systemic hypertension).
Third heart sound S3
Rapid ventricular filling (left ventricular failure, mitral regurg)
Fourth heart sound S4
Atrial systole against a stiff ventricle
Ejection click
Congenital bicuspid aortic valve, aortic stenosis, valvular pulmonary stenosis.
Midsystolic click
Mitral valve prolapse.
Target INR for mechanical aortic valve
3
Target INR for mechancial mitral valve
3.5
What infection precedes rheumatic fever?
Lancefield group A strep infection (scarlet fever, pharyngeal infection)
Major criteria for diagnosis of rheumatic fever?
Carditis 'Flitting' arthritis of major joints Subcutaneous nodules Erythema marginatum Sydenham's chorea
What precipitates recurrence of carditis after rheumatic fever?
Further infections, the Pill, pregnancy.
Causes of aortic stenosis
Senile calcification commonest. Also congenital (bicuspid, William’s syndrome), rheumatic heart disease.
Presentation of AS
Think of it in any presentation of elderly with chest pain, exertional dyspnoea or syncope.
Classic triad is angina, syncope and heart failure.
Tests for AS
ECG, echo.
Causes of AR - acute
Infective endocarditis, ascending aortic dissection, chest trauma.
Causes of AR - chronic
Chronic: congenital, connective tissue disorders (Marfan’s, Ehlers-Danlos), rh fever, Takayashu’s arteritis, rh arthritis.
Presentation of AR
Exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea.
Palpitations, angina, syncope, CCF
Corrigan’s sign
Carotid pulsation (AR)
de Musset’s sign
Head nodding (AR)
Quinke’s sign
Pulsation of nail bed (AR)
Duroziez’s sign
Murmur in femoral artery with pressure proximal to stethoscope.
Tests for AR
ECG, CXR (cardiomegaly, dilated aorta, pul oedema)
Echo is diagnostic.
Causes of tricuspid regurgitation.
RV dilatation, rheumatic fever, infective endocarditis, carcinoid syndrome, congenital, drugs.
Symptoms of tricuspid regurg.
Fatigue, hepatic pain on exertion, ascites, oedema.
Main cause of tricuspid stenosis
Rheumatic fever.
Causes of pulmonary stenosis
Turner’s, Noonan’s, William’s syndrome, Tetralogy of Fallot, rubella.
Rheumatic fever, carcinoid syndrome
Which valves is valvuloplasty used on?
Mitral or pulmonary stenosis if no calcification or regurg. Balloon catheter inflated across valve.
When would you suspect infective endocarditis?
Any time there is a fever and a new murmur. Fever lasting longer than a week in any at risk.
Acute heart failure and emboli.
Risk factors for infective endocarditis
Dermatitis, IVDU, renal failure, organ transplant, diabetes.
Abnormal valve/anatomy
Treatment for infective endocarditis
Amoxicillin, gentamycin
If penicillin allergic, vancomycin and gentamycin.
Add rifampicin if prosthetic valve unknown organism, or if staph.
Complications of bicuspid valves
Aortic stenosis or regurg, predispose to IE and aortic dilatation.
Atrial septal defect complications
Reversal of shunt leading to pulmonary hypertension. Paradoxical emboli.
Ventricular septal defect causes
Congenital, or post-MI.
Ventricular septal defect signs
Harsh pansystolic murmur on left sternal edge. Large holes are associated with pul hypertension.
Complications of VSD
AR, infundibular stenosis, pul hypertension, IE.
Coarctation of the aorta associations
Bicuspid valve, Turner’s syndrome.
Signs of coarctation
Radio-femoral delay, weak femoral pulse, raised BP, scapular bruit
Tetralogy of Fallot - basics
common cyanotic heart disorder involving VSD, pulmonary stenosis, right ventricular hypertrophy, aorta overriding VSD.
Tetralogy of Fallot presentation
Often acyanotic at birth. Difficulty in feeding, faiulre to thrive, clubbing.
Cyanosis common.
Heart conditions in systemic disease: acromegaly
High BP, hypertrophic cardiomyopathy
Heart conditions in systemic disease: amyloidosis
Restrictive cardiac myopathy, bright myocardium on echo
Heart conditions in systemic disease: Ankylosing spondylitis
Conduction defects, AV block, aortic regurg
Heart conditions in systemic disease: Behcet’s disease
AR, aortic and venous thrombi
Heart conditions in systemic disease: Cushing’s syndrome
htn
Heart conditions in systemic disease: Down’s syndrome
ASD, VSD, mitral regurg
Heart conditions in systemic disease: Ehlers-Danlos syndrome
Mitral valve prolapse, hyperelastic skin and aneurysms/GI bleeds. Joints loose and hypermobile, mutations exist e.g. in genes for procollagen.
Heart conditions in systemic disease: Friedrich’s ataxia
Hypertrophic cardiomyopathy, dilatation over time.
Heart conditions in systemic disease: haemochromatosis
AF, cardiomyopathy.
Heart conditions in systemic disease: Holt-Oram syndrome
ASD/VSD with upper limb defects
Heart conditions in systemic disease: HIV
Myocarditis, dilated cardiomyopathy, effusion, ventricular arrhythmias, inf. endocarditis, non-infective thrombotic endocarditis, RVF, metastatic Kaposi’s sarcoma.
Heart conditions in systemic disease: hypothyroidism
Sinus bradycardia, low pulse pressure, pericardial effusion, coronary artery disease, low voltage ECG.
Heart conditions in systemic disease: Kawasaki’s disease
Coronary arteritis similar to PAN, commoner than rheumatic fever as a cause of acquired heart disease.
Heart conditions in systemic disease: Klinefelter’s syndrome
ASD (psychopathy, learning difficulties, decreased libido, gynaecomastia, sparse facial hair and small firm testes).
Heart conditions in systemic disease: Marfan’s syndrome
Mitral valve prolapse, AR, aortic dissection. Look for long fingers and high-arched palate
Heart conditions in systemic disease: Noonan’s syndrome
ASD, pul stenosis, and low set ears.
Heart conditions in systemic disease: PAN
Small and medium sized vessel vasculitis + angina, MI, arrhythmias, CCF, pericarditis and conduction defects.
Heart conditions in systemic disease: rheumatoid arthritis
Conduction defects, pericarditis, pericardial effusion, myocardial fibrosis, myocardial ischaemia, conduction defects, cardiomyopathy.
Heart conditions in systemic disease: sarcoidosis
Infiltrating granulomas cause AVE block, ventricular or supraventricular tachycardia, myocarditis, CCF, restrictive cardiomyopathy. ECG may show Q waves.
Heart conditions in systemic disease: syphilis
Myocarditis, ascending aortic aneurysm
Heart conditions in systemic disease: systemic lupus erythematosus
Pericarditis/effusion, myocarditis, Libman-Sacks endocarditis, mitral valve prolapse and coronary arteritis.
Heart conditions in systemic disease: Systemic sclerosis
Pericarditis, pericardial effusion, myocardial fibrosis, myocardial ischaemia, conduction defects, cardiomyopathy.
Heart conditions in systemic disease: thyrotoxicosis
Increased heart rate, AF and emboli, wide pulse pressure, hyperdynamic apex, loud heart sounds, ejection systolic murmur, pleuropericardial rub, angina, high output cardiac failure.
Heart conditions in systemic disease: Turner’s syndome
Coarctation of the aorta (webbed neck)
Heart conditions in systemic disease: William’s syndrome
Supravalvular aortic stenosis.
Management of aortic stenosis
if asymptomatic then observe the patient is general rule
if symptomatic then valve replacement
if asymptomatic but valvular gradient > 50 mmHg and with features such as left ventricular systolic dysfunction then consider surgery
balloon valvuloplasty is limited to patients with critical aortic stenosis who are not fit for valve replacement
Most characteristic side effects of ACEI
Cough, hyperkalaemia and first dose hypertension
