EM EOR study guide /CARDIOVASCULAR ACUTE/SUBACUTE BACTERIAL ENDOCARDITIS

CARDIOVASCULAR ACUTE/SUBACUTE BACTERIAL ENDOCARDITIS A bacterial infection of the endocardium Duke criteria ◆ Positive blood culture for infective endocarditis (IE) ● Isolation of typical organisms from two positive cultures of blood samples drawn > 12 hours apart, or all of three or a majority of four separate cultures of blood ● Typical organisms include viridans strep, S. bovis, HACEK (H. aphrophilus, A. actinomycetemcomitans, C. hominis, E. corrodens, and K. kingae), or community-acquired S. aureus or enterococci ◆ Endocardial involvement as evidenced by positive echocardiogram for IE defined as… ● Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or ● Abscess, or ● New partial dehiscence of prosthetic valve Frequency of affected valves is aortic > mitral >> tricuspid Vascular phenomena ◆ Major arterial emboli ◆ Septic pulmonary infarcts ◆ Mycotic aneurysm ◆ Intracranial hemorrhage ◆ Conjunctival hemorrhages ◆ Splinter hemorrhages ◆ Janeway lesions Immunologic phenomena ◆ Glomerulonephritis ◆ Osler’s nodes ● Tender fingertip nodules ◆ Roth spots ● Retinal hemorrhages First line treatment is vancomycin ◆ Therapy can be narrowed with blood culture results ANGINA ARRHYTHMIAS PROLONGED QT SYNDROME QTc > 430 msec in men and > 450 msec in women Causes of prolonged QT (QT WIDTH) ◆ QT ● Prolonged QT syndromes including Romano-Ward and Jervell and Lange-Nielsen ◆ Wolff-Parkinson-White (WPW) syndrome ◆ Infarction ◆ Drugs ◆ Torsades ◆ Hypocalcemia, hypokalemia, hypomagnesemia Symptoms include syncopal episodes, predisposition to paroxysmal episodes of ventricular tachycardia and torsades de pointes by “R-on-T phenomenon” ◆ QRS fires at the same time (so, prematurely) as ventricular repolarization (T wave) is happening, so not all tissue is ready for depolarization If inherited, give beta blockers to decrease sympathetic stimulus and implantable overdrive pacemaker/defribillator SINUS BRADYCARDIA A sinus rhythm (P before every QRS complex) with upright P waves in I and aVF and narrow QRS complexes with a rate < 60 If the RR distance is at least one inch, consider…(One INCH) ◆ Overmedication ◆ Inferior wall MI, increased intracranial pressure ◆ Normal variant ◆ Carotid sinus hypersensitivity ◆ Hypothyroidism SINUS TACHYCARDIA HR > 100 bpm and regular, usually < 150, with a P wave prior to every QRS complex and upright P waves in I and aVF ATRIAL ECTOPY WANDERING ATRIAL PACEMAKER (WAP) More than 3 different P wave morphologies QRS following each P wave Usually asymptomatic but the patient may complain of palpitations or anxiety MULTIFOCAL ATRIAL TACHYCARDIA (MAT) Wandering atrial pacemaker with a rate > 100 bpm Associated with COPD and theophylline overdose Rate is often difficult to control WOLFF-PARKINSON-WHIT