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1

Most common complications of endocarditis

CHF
CNS disorder
Peripheral embolization

2

Cutaneous embolic phenomena of endocarditis

1. Splinter or subungual hemorrhages of finger/toenails
2. Osler nodes - (small, tender subcutaneous nodules on the pads of the fingers or toes)
3. Janeway lesions - (small hemorrhagic painless plaques on the palms or soles)

3

Admitting for endocarditis

1. Febrile injection drug users
2. Admit all patients with a cardiac prosthetic valve and fever (or persistent malaise, vasculitis, or new murmur)

4

Abx for endocarditis

1. Uncomplicated hx - Ceftriaxone, Oxcacillin, or Vancomycin PLUS Gentamicin or Tobramycin

2. Injection drug users: Nafcillin + Gentamicin + Vancomycin

3. Prosthetic heart valve: Rifampin + Gentamicin + Vancomycin

5

Iatrogenic causes of acute heart failure

Recent addition of negative inotropic drugs (e.g., calcium channel blocker, β-blocker)

Initiation of salt-retaining drugs (e.g., NSAID, steroids, thiazolidinediones- glitazones)

Inappropriate therapy reduction

New antiarrhythmic agents

6

Acute heart failure with hypotension, tx:

Ionotropic therapy:
norepinephrine, dopamine, or dobutamine

7

Hypertensive acute heart failure, tx:

1. O2
2. Nitroglycerin (venous and arterial dilator). Sublingual then IV if needed
3. IV loops diuretics - Furosemide of Bumetanide for volume overload
4. Admite or discharge after obs

8

Diuretics without vasodilators in acute hypertensive HF?

NO - vasodilators first
Diuretics (furosemide most commonly used) administered alone without vasodilators for hypertensive heart failure may increase mortality44 and worsen renal dysfunction.

successful management of blood pressure and cardiac filling pressure creates marked improvement in respiratory status long before any diuresis.

9

Contraindications to using vasodilators in acute HF

Signs of hypoperfusion or hypotension

Flow-limiting, preload-dependent states such as right ventricular infarction, aortic stenosis, hypertrophic obstructive cardiomyopathy, or volume depletion increase the risk of vasodilator-associated hypotension

10

Flow-limiting, preload-dependent states

Right ventricular infarction
Aortic stenosis
Hypertrophic obstructive cardiomyopathy
Volume depletion

11

Normotensive HF tx:

Diuresis first

12

Loop diuretic electrolyte complications

Hypokalemia - keep an eye out for increasing QT interval
(also hypocalcemia, hypomagnesemia)

13

Drugs to avoid in Heart Failure

Calcium Channel Blockers (verapamil, diltiazem, amlodipine,

NSAIDs

14

High-risk physiologic markers in ED patients with acute heart failure associated with morbidity and mortality

Renal dysfunction
Low BP
Low sodium
Elevated BNP or Troponin

15

Diagnosis of STEMI vs NSTEMI

STEMI = ECG changes in presence of suggestive sx

NSTEMI = depends on cardiac biomarkers, but may include ECG changes

16

Inferior wall AMIs on ECG

ST-segment elevations in II, III, and aVF

get V4 on right side to check for ST elevation there too!

17

ST-segment elevations in II, III, and aVF + V4 (right side)

Suggestive of right ventricular infarction = NO NITRO

18

Reciprocal ST-segment changes—those in leads away from or opposite the elevation area—

-- are from subendocardial ischemia and denote a larger area of injury risk, an increased severity of underlying CAD, more severe pump failure, a higher likelihood of cardiovascular complications, and increased mortality.

In general, the more elevated the ST segments and the more ST segments that are elevated, the more extensive is the injury.

19

In the setting of an inferior wall AMI (II, III, aVF), ST-segment elevation in at least one lateral lead (V5, V6, or aVL) with an isoelectric or elevated ST segment in lead I is strongly suggestive of lesion i which artery

Left circumflex

20

The presence of ST-segment elevation in lead III greater than that in lead II predicts

a right coronary artery occlusion

21

ST seg elevation in lead III greater than lead II, accompanied by ST-segment elevation in V1 or a V4R, it predicts

a proximal right coronary artery lesion with accompanying right ventricular infarction

22

pattern of abnormal T waves in the precordial leads V2and V3 associated with critical stenosis of the left anterior descending artery

Wellen's sign (deeply inverted T waves or biphasic)

V2, V3 especially

Present in 18% of unstable angina

23

STEMI/NSTEMI/unstable angina initial tx:

1. Aspirin
2. Clopidogrel, Ticagrelor, Prasugrel
3. Nitroglycerine
4. Beta blockers
5. Antithrombin > Enoxaparin, unfract heparin, or fondaparinux

24

Antithrombin options for STEMI/NSTEMI tx

Enoxaparin (Lovenox, LMWH)
Unfractionated heparin
Fondaparinux

all bind antithrombin III, inhibit Xa and thrombin

25

Anti-platelet options for STEMI/NSTEMI/unstabe angina

Aspirin +
Clopidogrel
Ticagrelor
Prasugrel

26

Fibrinolytic therapy is indicated for patients with STEMI (as a reperfusion option) if

time to treatment is <6 to 12 hours from symptom onset and the ECG has at least 1 mm of ST-segment elevation in two or more contiguous leads

27

Evidence of bundle branch block on EKG

1. Widened QRS (> 120ms)

28

Normal V1, V6

V1, little positive then big negative QRS

V6, little negative then big positive QRS

29

LBBB V1, V6

V1, one big negative, "W"

V6, notched big positive, "M"

30

RBBB V1, V6

V1 "terminal R"/peaked R wave, complex looks "M'

V6, "slurred S", looks kinda "W'

31

R BBB, L BBB pneumonic

WLM MRW
WILLIAM MARROW

32

200-300 BPM
doesnt last long
can be SOB, dizzy, syncope, palpitations

Supraventricular tachycardia (AVRT, AVNRT)
Ex. Wolf Parkinson White syndrome

33

Supraventricular tachycardia on EKG

Buried p waves

34

Common causes fo syncope

1. Vasovagal
2. Cardiac
3. Orthostatic
4. Medication related
5. Neurologic
6. Unknown

35

Classic sypmtom constellation in aortic stenosis

Chest Pain
Dyspnea on exertion
Syncope

36

stiff noncompliant left ventricle, diastolic dysfunction, and outflow tract obstruction

hypertrophic cardiomyopathy

37

Hypomagnesemia on EKG

torsades de pointes

38

1st degree AV block

PR interval > 200 ms

39

2 types of 2nd degree AV block

Mobitz 1 (Wenchebach) : PR interval going, going, QRS dropped

Mobitz 2 - PR interval > 200ms, constant, doesn't get longer - then QRS dropped

40

Longer longer longer drop

that is a wenchebach

Mobitz 1, 2nd degree AV block
PR interval is > 200ms, gets longer, longer, then QRS dropped

41

3rd degree AV block

Atria and ventricle conduct independently

Constant P-P intervals
Constant Q-Q intervals

42

Symptoms of A blocks

bradycardia
dizziness
syncope

43

patient is unstable, has a bradycardic dysrhythmia - most likely

3rd degree AV block

followed ( much less likely) by 2nd degree

44

Indications for treating bradydysrhythmias

HR < 50 bpm + hypotension/perfusion

45

Pharm tx for brady-dysrhythmia due to sinus and AV nodal diseas

Atropine

46

Effective in terminating narrow QRS complex reentrant tachydysrhythmias involving the AV node

Adenosine

47

Effective in terminating narrow QRS complex reentrant tachydysrhythmias involving the AV node

AND reducing ventricular rate in atrial fibrillation or flutter

Adenosine
Verapamil
Diltiazem
Metropolol
Propanolol

48

Tachycardias are categorized as

Supraventricular - "narrow complex tachycardia"
Ventricular - "wide complex tachycardia"

49

Ventricular tachycardia tx

Amiodarone
Cardioversion

50

Supraventricular tachycardia with aberrency tx

Adenosine

51

Afib + WolffPrkWht tx

Amiodarone or procainamide

52

Torsades de pointes tx

Magnesium sulfate 2g IV

53

Polymorphic ventricular tachycardia tx

Cardioversion

54

Tx for symptomatic SA node arrest

Atropine

cardiac pacing for recurrence