Flashcards Cardiology: L8 Traumatic infectious and inflammatory | Quizlet

What is the leading cause of death and disability among young people in the US?

Trauma

Penetrating Traumas

- missile or knife wound to thorax or upper abdomen

- low, medium, or high velocity

- cardiac penetration injuries are highly lethal

Low velocity cause

Knife wounds

Medium velocity cause

Shotgun injuries

High velocity cause

Rifle or shrapnel injuries

What part of the heart is most frequently injured with Penetrating Trauma

Right ventricle due to anterior position

Penetrating Traumas: Primary presentation

Hemorrhage and tamponade

How does tamponade occur

When clot and surrounding pericardial fat partially seal the pericardial defect

Penetrating Traumas: dx gold standard

Subxiphoid window

Penetrating Traumas tx

- most can be repaired through a left thoracotomy

- emergent thoracotomy if unstable or pulseless from low velocity trauma

- relieve tamponade and stop life threatening hemorrhage

Blunt Cardiac Trauma causes

- motor vehicle collision

- rapid deceleration mechanism or a direct blow to the precordium

- falls from heights

- sports related injuries

Blunt Cardiac Trauma dx

Difficult due to asx on initial presentation

Blunt Cardiac Trauma: EKG

- nonspecific ST and T wave changes

- arrhythmias self-limiting

Blunt Cardiac Trauma: dx for unstable pts

Echocardiogram

Blunt Cardiac Trauma Management

Manage by trauma team and consults with cardio and cardiothoracic surgery teams

Great Vessel Injury

- 90% from penetrating trauma; high mortality

- blunt trauma can cause cardiac rupture

- ~20% w/ descending aortic transections survive to reach medical care

Pericarditis

- inflammation of the pericardium

- can be from infection, systemic dz, neoplasm, radiation, drug toxicity, etc

Types of Pericarditis (4)

- acute

- Incessant

- Recurrent

- Chronic

Acute Pericarditis

new episodes lasting

Incessant Pericarditis

>4-6wks but

Recurrent Pericarditis

recurrence after sx free interval ≥4-6 wks

Chronic Pericarditis

> 3mo

Infectious Pericarditis Causes (3)

- viral (mcc): enterovirus

- purulent: S. aureus, S. pneumoniae

- TB

Non-infectious Pericarditis Causes (5)

- early post MI

- Dressler Syndrome

- uremic

- neoplastic

- radiation/drug induced

Early Post MI Pericarditis

occurs within several days of a transmural MI due to inflammation adjacent to myocardial necrosis

Dressler Syndrome Pericarditis

delayed immune=-mediated pericarditis occurring wks-mo after MI

Pericarditis sx (5)

- substernal CP: acute, sharp and pleuritic

- improves with sitting upright

- worsens when taking a deep breath

- can radiate to neck, shoulder, back, or epigastrium

- friction rub early; disappears with increased pericardial fluid

Pericarditis: if pericardial effusion develops sx (2)

- dyspnea

- rapid respiratory rate

Pericarditis: if pericardial tamponade develops sx (2)

- pulsus paradoxus

- JVD

Pericarditis Work up (4)

- ECG

- CXR

- Echo

- Labs: CBC, BMP, cardiac enzymes, ESR, CRP

Pericarditis ECG

diffuse ST elevation and PR depression

Pericarditis dx (at least 2/4 required)

- sharp, pleuritic CP

- pericardial friction rub

- consistent changes on ECG

- new or worsening pericardial effusion

Pericarditis Viral tx (2)

- NSAIDs or ASA x 1-2wks + Colchicine x 3mo

- PPI for gastroprotection

Pericarditis NSAIDs you can use (3)

- Ibuprofen 600-800mg TID 1-2wks

- Indomethacin 25-50mg TID 1-2wks

- ASA 750-1000mg TID 1-2wks

Pericarditis Purulent tx

- emergency surgical drainage

- IV Abx (vancomycin, ceftriaxone, and cipro)

Pericarditis TB tx

RIPE regimen

Pericardial Effusion

accumulation of fluid in the pericardial cavity

Pericardial Effusion: assessment of size

Transthoracic Echocardiography (TTE)

Pericardial Effusion: sizes (3)

- small:

What is a large effusion w/ acute pericarditis associated with a higher risk of?

Development of a cardiac tamponade

Pericardial Effusion with what has a poorer prognosis?

Pulmonary HTN

Pericardial Effusion: what does the rate of fluid accumulation determine?

Hemodynamic consequences

Does a larger Pericardial Effusion have a greater chance of causing tamponade?

No it depends on the rate of fluid accumulation, not the size

Pericardial Effusion sx (6)

- dyspnea (mc)

- tachypnea (mc)

- pleuritic chest discomfort

- cough/hoarseness

- fatigue

- hiccups

What sx is concerning for tamponade?

Syncope

Pericardial Effusion PE (7)

- normal PE unless tamponade present

- tachycardia

- hypotension

- muffled heart sounds

- elevated JVP

- pulsus paradoxus

- electrical alternans

What triad are Pericardial Effusion and Tamponade associated with?

Beck Triad

Beck Triad

hypotension

JVD

muffled heart sounds

Pericardial Effusion and Tamponade dx Labs (5)

- cardiac enzymes

- ESR

- CRP

- thyroid panel

- rheumatoid factor

Pericardial Effusion and Tamponade Imaging

- CXR

- Cardiac CT/MRI

- TTE

- EKG

- pericardiocentesis (unstable; last resort)

- pericardial fluid anaysis

When should pericardiocentesis be performed? (3)

- cardiac tamponade

- large pericardial effusions

- unstable pts

Pericardial Effusion and Tamponade CXR (2)

- enlarged cardiac silhouette (water bottle heart)

- pericardial fat stripe

Pericardial Effusion and Tamponade EKG (3)

- low voltage QRS

- ectopy (extra or skipped beats)

- tachycardia

Constrictive Pericarditis

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

- similar to restrictive cardiomyopathy

Constrictive Pericarditis mc cause

Tuberculosis

Constrictive Pericarditis other causes (5)

- viral or idiopathic

- immune mediated or neoplastic

- purulent bacterial (20-30%)

- post surgery/radiation

- drug induced

Constrictive Pericarditis sx (8)

- slowly progressive dyspnea

- fatigue/weakness

- chronic edema

- hepatic congestion ascites

- Elevated JVP

- Kussmaul sign

- pericardial "knock" in early diastole

- A.Fib

Kussmaul sign

Increase JVP with inspiration

Constrictive Pericarditis dx

- CXR

- Echo

- Cardiac CT/MRI

- Uncertain: Invasive hemodynamics (swan cath)

Constrictive Pericarditis CXR

normal heart size of cardiomegaly

Constrictive Pericarditis Echo

Septal "bounce" reflecting rapid early filling

Constrictive Pericarditis tx (3)

- tx underlying cause

- diuretics for venous congestion/edema

- surgical pericardiectomy (if diuretics don't work)

What sign can you see in Pericarditis on catheterization?

Square root sign: abrupt stop in diastolic filling

Rheumatic Fever

- GAS pharyngitis/tonsillitis without abx treatment

- 5-15yo

Rheumatic Fever sx (6)

- high fever, malaise, fever

- erythema marginatum "target lesions"

- subcutaneous nodules

- migratory polyarthritis

- valvulitis/pancarditis

- chorea (1-8mo after)

Rheumatic Fever dx

Jones Criteria

Jones Criteria: initial ARF (2)

2 major manifestations

or

1 major + 2 minor

Jones Criteria: recurrent ARF (3)

2 major

or

1 + 2 minor

or

3 minor

Jones Criteria: Major criteria in low risk (5)

- carditis

- polyarthritis

- chorea

- erythema marginatum

- subcutaneous nodules

Jones Criteria: Major criteria in mod-high risk (5)

- carditis

- monoarthritis or polyarthritis

- chorea

- erythema marginatum

- subcutaneous nodules

Jones Criteria: Minor criteria in low risk (4)

- polyarthralgia

- fever

- ESR ≥60mm in 1st hr and/or CRP ≥ 3.0 mg/dL

- prolonged PR interval

Jones Criteria: Minor criteria in mod-high risk (4)

- monoarthralgia

- fever

- ESR ≥ 30mm/h and/or CRP ≥ 3.0 mg/dL

- prolonged PR interval

Infective Endocarditis

- infection of the heart valves or mural endocardium that leads to the formation of vegetations which destroys the cardiac tissue

- >age, M>F

- cardiac devices, prosthetic valves

- IV opioid epidemic

Infective Endocarditis: mc valves

Mitral valve and aortic valve

Infective Endocarditis: what valve is most common with IV drug use?

Tricuspid valve

2 Forms of Infective Endocarditis

- acute infective endocarditis

- sub acute infective endocarditis

Acute Infective Endocarditis (3)

- infection of previously normal heart valve

- days to weeks

- S. aureaus + aggressive + attack normal valve

Sub Acute Infective Endocarditis

- infection by organism of lower virulence of an already damaged/deformed valve

- weeks to months

- S. Viridans + indolent + usually abnormal valve

Infective Endocarditis Pathogenesis

Valve injury --> platelet/fibrin --> bacteremia --> vegetation

Native Valve Endocarditis Pathogens (2)

- S. aureaus

- Streptococci Viridans

IV Drug (lemon juice) use Endocarditis Pathogen

S. aureus

Prosthetic Valve Endocarditis pathogen (3)

- S. aureus

- S. epidermidis

- gram (-) and fungi

Mouth pathogen

Viridans

Skin/Blood pathogen

S. aureus

GI/GI pathogen

Enterococcus

Colon pathogen

S. gallolyticus

Infective Endocarditis sx mneumonic

FROM JANE

Infective Endocarditis sx: FROM JANE

- Fever (mc)

- Roth spots

- Osler nodes

- Murmur

- Janeway lesions

- Anemia

- Nail-bed hemorrhages

- Emboli

Osler Nodes + Janeway lesion

Roth Spots

What is Infective Endocarditis until proven otherwise?

New/acute aortic regurgitation

When should you think Infective Endocarditis?

Stroke + fever

Infective Endocarditis dx (2)

- blood cultures

- Echo TTE

Infective Endocarditis: How to obtain blood culture

- 3 sets of blood cultures from separate venipuncture sites BEFORE Abx

- 10mL

Infective Endocarditis: dx criteria

Duke - ISCVID Criteria

Duke - ISCVID Criteria: Definite IE

2 major

or

1 major + 3 minor

or

5 minor

Duke - ISCVID Criteria: possible IE

1 major + 1 minor

or

3 minor

Duke - ISCVID Criteria: Major categories (3)

- microbiologic

- imaging

- surgical

Duke - ISCVID Criteria: Microbiologic (2)

- typical IE organisms from ≥2 culture sets

- less typical organisms from ≥ 3 culture sets

Duke - ISCVID Criteria: Imaging (3)

- echo or cardiac CT showing vegetations, abscess, perforation, aneurysm, or fistula

- significant new valvular regurgitation

- abnormal FDE-PET/CT involving valve/prosthetic material