arbi ayvazian, do- valvular disease, conduction disorders & bradydysrhythmias- armc emergency...
TRANSCRIPT
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Valvular Disease, Conduction Disorder & Bradydysrhythmias
Arbi Ayvazian D.O PGY2Emergency Medicine
ARMC 1/2014
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Valvular Disorder
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Valvular Disorder
Things to know
Endocarditiis presentation
Murmurs, Rheumatic HD
Specific high risk diseases
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Infective Endocarditis
Risk Factors: Abnormal or artificial valve
Mitral valve most common, IVDA -> Tricuspid (staph)
Most common bug -> Staph
Tooth extraction -> Strep
Acute -> high fever, murmur, flu like symp., younger
Subacute -> Strep viridans, Anemia, older
Prophylaxis? Depends on bug and procedure
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Infective Endocarditis
Vasculitis and Embolic manifestations
Janeway lesions: Non-tender, hemorrhagic, flat, on palms and soles.
Osler nodes -> tender, tips of fingers and toes
Roth spots and splinter hemorrhages
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Infective Endocarditis
Dx by echo, blood cultures, high ESR/CRP
Rx: Vancomycin for Staph, PCN for Strep
Prophylaxis if abnormal valve and procedure
Procedure site determines bug and Abx
Classic broad question -> dental and Amoxicilin, GI/GU more gram negative coverage
Controversial in mitral valve prolapse (no on boards)
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End Point of Valve Disease
Heart Fails and dilates
Valves become regurgitant
ECG shows LVH as ventricles expand
LBBB develops as heart and conduction system stretches which is poor prognostic sgin
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Murmurs: MR. ASS, MS.AID
Mitral Regurgitation
Aortic Stenosis
SYSYTOLIC
Mitral Stenosis
Aortic Insufficiency
DIASTOLIC
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Aortic Stenosis
Symptoms progress from : SOB, CHF, Syncope (bad!)
Murmur: Systolic, up into the neck, slow carotid upstroke
ECG : LVH, LBBB
Exercise-induced syncope
Vasodilators can make it worse
Rx: Surgical (moderate to severe)
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Aortic Regurgitation
THINK AORTIC DISECCTION
Murmur: Diastolic, lower left, sternal border
LOTS Signs: water hammer pulse, Austin Flint Murmur, Duroziez’s Murmur, Quincke’s pulse, de Musset’s sign, Lighthouse, Landolfi’s, Beck’s, etc, etc, etc.
Rx: Afterload reduction…..surgical
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Mitral Stenosis
Cardiovascular collapse in pregnant patient during delivery
Murmur: Diastolic, Opening SNAP
Atrial fib common, blood backs up into left atrium -> lungs = CHF, Chronic -> Hemoptysis
AF can cause decompensation, crash quick due to loss of KICK, CARDIOVERT if Acute.
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Mitral Regurgitaion
Ischemia + SHOCK + new MURMUR = ruptured chordae tendineae/papillary muscle
Murmur: Radiates widely, esp. into axilla
Atrium stretches and produces A. Fib
Mitral valve prolapse can get worse and overtime lead to regurgitation
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Conduction Disease
Normal Conduction system
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Bundle Branch and Fascicular Blocks
RBBB:
ECD: Wide QRS, Abnormal QRS complexes in right precordical leads (V1- V2) (rSR’). We know this.
Incomplete RBBB
RBBB block morphology with a normal QRS width
Common finding in children and young adult
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LBBB
ECG: Wide QRS.
Abnormal morphology: RR’ or large wide R (I, V5, V6) Anormal repol., QS or RS pattern in right precordial leads (V1,V2)
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Hemi Blocks
Left anterior vs posterior block
Anterior more common (left coronary blood supply)
Ant: left axis deviation, QR (I, aVL), RS (II,III, aVF)
Post: Right axis, RS (I, aVL), QR (II,III, aVF)
Bifascicular block
Most common combination: LAF with RBBB
Marker for advance cardiac disease
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Heart Blocks
SA node: Blood supply Rt corornary (65%), circumflex (25%), both (10%)
AV node: Post. Descending artery (rt coronary 90%)
SA blocks (sick sinus, sinus pause, sinus arrest, etc.)
Absence of P and ORS, and T cycles
Ventricular activity -> dependent on escape rhythm
Rx: pacemaker + medication to suppress tachydysrhythmias
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AV node Blocks
First –Degree AV Block – conduction delay in AV node, PR prolong
Second –Degree Block – intermittent loss of conduction between artia and ventricle
Mobitz I (Wenckebach) : PR increases until dropped beat, generally goes not need emergency Tx
Mobitz II: PR normal from beat to beat with an occ. Abrupt dropped beat.
Rx: Can progress to complete block, pacer.
Third-degree AV Block – No conduction through AV
No assos. of P and QRS
Pace and pacemaker
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Bradydysrhythmia
Sinus Bradycardia
<60bpm, high vagal tone, medications, hyothyroidism
Signs and symptoms – generally asymptomatic, or signs of hypoperfusion
Rx: Direct towards degree of patient symptoms, atropine, pacing, vasopressors.
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BradydsyrhythmiaSimplified!
Stable or Unstable?
Wide or Narrow?
Slow or VERY slow
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Bradydysrhythmia
WHY IS THIS PATIENT BRADYCARDIC
Ischemia Drugs Electrolytes
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Stable or Unstable
Same criteria as tachycardia
BP, mentation, awake and talking? -> perfusion
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Wide or Narrow
Wide (much worse than narrow)
= Block below AV node
= Slower = More likely to Stop = NOT atropine sensitive
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Wide or Narrow
Narrow
= more stable
= Faster
=Atropine sensitive
=? Block at AV node
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Treatment of Bradycardia
IVF, O2, Monitor
TCP (often fails) or TVP
Atropine (go slow, not good on wide QRS)
Epinephrine
Dopamine