Cardio Exam 4

leading cause of death/disability among young people?

leading injury in trauma deaths? second leading?

trauma

neurologic -- cardiac

mechanism of injury (of penetrating trauma) may be categorized as...?

low, medium, or high velocity

velocity matters -- why?

damage is directly related to the amount of energy exerted

low/med/high velocity?

knife wounds

low

2 multiple choice options

low/med/high velocity?

shotgun injury

medium

2 multiple choice options

low/med/high velocity?

rifle or shrapnel injury

high

2 multiple choice options

which ventricle is most frequently injured in traumatic cardiac penetration injuries?

right

1 multiple choice option

primary presentation of traumatic cardiac penetration injuries? (2)

- hemorrhage

- tamponade

why does tamponade occur in traumatic cardiac penetration injuries?

occurs when clot and surrounding pericardial fat partially seal the pericardial defect

diagnostic gold standard for traumatic cardiac penetration injuries?

subxiphoid window

tx of most cardiac penetrating wounds?

principle objective of tx?

left thoracotomy

relieve tamponade + stop life-threatening hemorrhage

______ cardiac trauma is involved in up to 20% of all motor vehicle collision deaths

blunt

most common cause of blunt cardiac trauma?

MVA

severe sudden abdominal compression can acutely increase what to the heart?

this results in?

pressure and blood flow

right-sided rupture

why is diagnosis of blunt cardiac injuries difficult?

majority of pts are asymptomatic on initial presentation

all pts who have a significant mechanism of injury (for blunt cardiac trauma) should have what?

screening ECG

ECG findings suggestive of blunt cardiac trauma? (2)

- nonspecific ST and T wave changes

- arrhythmias (afib, atrial flutter, PVCs)

in blunt cardiac trauma, what arrhythmias are uncommon in patients surviving to the hospital?

vtach and vfib

general tx of blunt cardiac trauma?

tx symptoms

tx of blunt cardiac trauma w/ arrhythmias?

rate control + suppression of ectopy

what should you get for blunt cardiac trauma w/ hemodynamic instability?

definitive ECHO

tx of blunt cardiac trauma w/ severe ventricular dysfunction and low CO?

inotropic support (to avoid primary ischemic event)

if all other tx fails, what else can be done for blunt cardiac trauma?

intra-aortic ballon counterpulsation

(T/F) pts sustaining significant blunt/penetrating cardiac injuries require long-term follow-up

true

1 multiple choice option

great vessels of the chest include...? (3)

- aorta

- major branches at the aortic arch (subclavian, carotid, innominate)

- major pulmonary arteries

more than 90% of thoracic great vessel injuries are caused by?

penetrating trauma (high mortality)

blunt trauma can cause what?

survival is most likely if...?

cardiac rupture involve any chamber or great vessel

if injury is to one of the atria or the RV

what is an aortic transection?

typically caused by?

aortic isthmus is torn where the aorta is tethered by the ligamentum arteriosum

MVA sudden deceleration

criteria for acute pericarditis (need 2 of 4)?

- pericardial chest pain (sharp, pleuritic)

- pericardial rub

- new widespread ST elevation or PR depression

- new or worsening pericardial effusion

incessant pericarditis is defined by...?

duration (lasts longer than 4-6 wks but <3 months w/o remission)

recurrent pericarditis is defined by...?

one reported episode of pericarditis in pt who has been symptom-free for at least 4-6 wks

chronic pericarditis is defined by...?

persists for >3 months

what are the 4 categories of pericarditis?

- acute

- incessant

- current

- chronic

infectious causes of acute pericarditis? (3)

- viral (most common cause)

- purulent

- TB

most common viruses causing acute pericarditis?

enteroviruses -- coxsackie and echovirus

most common purulent causes of acute pericarditis?

s. aureus, s. pneumoniae, other streptococci

non-infectious causes of acute pericarditis? (7)

- uremic (complication of CKD)

- neoplastic process (common cause of pericardial tamponade)

- post-MI (Dressler syndrome)

- radiation (constrictive d/t fibrotic process)

- autoimmune

- drug induced

- pericardial injury

s/sxs of pericarditis? (4)

- substernal chest pain

- friction rub (early -- disappears w/ increased pericardial fluid)

- dyspnea, tachypnea (if pericardial effusion develops)

- pulsus paradoxus, JVD (if pericardial tamponade develops)

characteristics of the substernal chest pain (in acute pericarditis)? (4)

- acute, sharp, pleuritic

- improves w/ sitting upright and worsens if supine

- may radiate to neck, shoulders, back, or epigastrium

- may be febrile

workup for pericarditis? (4)

- ECG

- CXR

- ECHO

- labs (CBC, BMP, cardiac enzymes, ESR, CRP)

why do you need an ECHO for evaluating pericarditis?

to exclude pericardial effusion and tamponade

tx of viral (or idiopathic) pericarditis?

what meds can you give?

self-limiting

NSAIDs/aspirin + colchicine

when do you NOT give NSAIDs for pericarditis?

if myocarditis present (use aspirin instead)

tx of purulent pericarditis?

emergency surgical drainage (pericardial window) + IV abx

tx of pericarditis caused by TB?

what if calcific form?

4 drug anti-TB regimen (RIPE) + prednisone

pericardiectomy

pericardial effusions can be classified as...?

- acute

- subacute

- chronic (>3 months)

pericardial fluid accumulates d/t an increase in its production as a result of what?

can also be d/t what?

inflammation of the serosal layers (exudate)

impaired lymphatic drainage of pericardial space related to increased central venous pressure (transudate)

most common cause of pericardial effusions in developed countries?

followed by what?

idiopathic

infectious causes, cancer, and connective tissue d/os

most common cause of pericardial effusions in developing countries?

TB

tamponade -- intrapericardial pressure =

>15 mmHg

tamponade --> restricts venous return and ventricular filling --> ??? --> shock and death

SV and arterial pulse pressure fall + HR and venous pressure rise

assessment of pericardial effusion size is determined by what?

transthoracic echocardiography (TTE)

TTE can differentiate ______ from ______ effusions

circumferential from loculated

presentation of pericardial effusions/tamponade? (7)

- dyspnea (most common)

- pleuritic chest pain

- cough

- fatigue

- hoarseness

- hiccups

- syncope (concerning for tamponade)

sxs in pericardial effusions/tamponade are most commonly associated w/ what?

rapidly accumulating effusions

phys exam findings of pericardial effusions/tamponade? (6)

- normal (most common unless tamponade present)

- tachycardia (most common and can present w/o tamponade)

- hypotension

- muffled heart sounds

- elevated JVP

- pulsus paradoxus

components of beck's triad? (3)

- JVD

- hypotension

- muffled heart sounds

CXR finding that suggests pericardial effusion/tamponade?

water bottle heart

ECG findings w/ pericardial effusion/tamponade?

low voltage QRS, ectopy, tachycardia

diagnostic and therapeutic procedure that can be used for pericardial effusion/tamponade (if large, acute, and shock state)?

pericardiocentesis

tx of pericardial effusion? (2)

- tx underlying cuase

- pain control (NSAIDs and colchicine)

routine diagnostic pericardiocentesis and/or pericardial biopsy are not indicated unless?

high index of suspicion for a bacterial, fungal, or protozoal infectious etiology or suspicion of cancer

when should pericardiocentesis be performed? (2)

- cardiac tamponade

- large pericardial effusions

constrictive pericarditis

occurs when a thickened fibrotic pericardium impedes normal diastolic filling and produces chronically elevated venous pressures

most common cause of constrictive pericarditis?

TB

sxs of constrictive pericarditis? (6)

- slowly progressive dyspnea

- fatigue and weakness

- chronic edema

- hepatic congestion (ascites)

- elevated JVP

- kussmaul sign

kussmaul sign

failure of JVP to fall w/ inspiration

with constrictive pericarditis, the apex may do what?

what can be heard in early diastole?

retract w/ systole

pericardial "knock"

definitive diagnostic procedure for constrictive pericarditis?

cardiac cath (differentiates constrictive pericarditis from restrictive cardiomyopathy)

what will ECHO show w/ constrictive pericarditis?

septal "bounce" (reflecting rapid early filling)

tx of constrictive pericarditis? (3)

- tx underlying cause

- anti-inflammatory meds (if inflammatory)

- diuretics (for venous congestion and edema)

if diuretics are no longer working for constrictive pericarditis, what tx?

surgical pericardiectomy

if streptococcal infxs are treated within _____ of onset, RF is usually prevented

8 days

after a heart-damaging attack of RF, reinfx must be prevented w/...?

long-term prohylaxis to prevent development of rheumatic heart disease (RHD)

RHD is d/t recurrent immune attack on cardiac tissue precipitating the formation of...?

fibrotic cardiac tissue

major criteria in low-risk populations (Jones criteria)? (5)

- carditis (clinical or subclinical)

- polyarthritis ONLY

- chorea

- erythema marginatum

- subcutaneous nodules

major criteria in moderate- and high-risk populations (Jones criteria)? (5)

- carditis (clinical or subclinical)

- polyarthritis OR monoarthritis

- chorea

- erythema marginatum

- subcutaneous nodules

infective endocarditis (IE)

microbial infx of the heart valves or mural endocardium that leads to the formation of vegetations composed of thrombotic debris and organisms, which leads to destruction of the underlying cardiac tissue

most common valves affected in IE?

mitral and aortic

IE affecting the tricuspid valve is most commonly involved with what?

IV drug use

characteristics of ACUTE infective endocarditis? (2)

- infection of previously normal heart valves by highly virulent (staphylococcus aureus) organisms that rapidly produces necrotizing and destructive lesions

- death can occur within days to weeks (despite appropriate tx w/ abx and surgery)

characteristics of SUBACUTE infective endocarditis? (2)

- infection by organisms of lower virulence (streptococci viridans) that causes insidious infections of deformed valves with overall less destruction

- disease has course of weeks to months and cure can be achieved w/ abx

venturi effect

decrease in pressure when blood flows through a stenosis at high velocity

how does the venturi effect affect bacteria?

bacteria accumulate in areas of lower pressure or the site of jet impaction

in aortic valve insufficiency/regurgitation, where would bacteria tend to form?

ventricular side

in mitral valve insufficiency/regurgitation, where would bacterial tend to form?

atrial side

most common source of pathogens causing IE?

IV catheters (25% of cases are hospital-acquired)

what type of procedure put you at risk for IE?

what organism is this associated with?

dental procedures

streptococcus viridans

what bacterial factors help bacteria cause IE? (2)

- adherence

- biofilm formation

what causes the adherent properties of oral strep (s. viridans), GI strep (s. bovis), and candida albicans?

high dextran coating

what causes the adherent properties of s. aureus?

binders to fibrinogen and fibronectin

how does biofilm formation benefit bacteria?

protects them and makes them more resistant to abx

classifications of IE? (4)

- native valve endocarditis (NVE)

- prosthetic valve endocarditis (PVE)

- IV drug use (IVDU)

- nosocomial

most common cause of IVDU?

s. aureus

most common causes of PVE? (2)

- s. aureus

- s. epidermis

majority of bacteria causing IE are gram-_____ organisms

most common bacterial causes?

gram-POSITIVE

staphylococcus, streptococcus, enterococcus

gram-negative bacteria causing IE?

- HACEK (haemophilus, actinobacillus, cardiobacterium hominis, eikenella corrodens, kingella)

- pseudomonas aeruginosa

- enteric organisms (e. coli, proteus, klebsiella, serratia)

pseudomonas and serratia are causes of endocarditis in what population of pts?

most common risk factor?

injecting drug users

healthcare contact

most common cause of acute NVE?

s. aureus

most common cause of subacute NVE?

s. viridans (then enterococcus)