1. Staph aureus 2. Coag neg Staph

Endocarditis Flashcards by Lux Smith

chest pain ddx in IVDU

MI
PE
Aortic dissection
Tension pneumothorax
Esophageal rupture
Injection drug use + fever  infection

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thinking endocarditis you want to order these labs

Echo?, CXR, blood cultures, EKG
Admit, +/- empiric abx

if you think endocarditis you NEED BLOOD CULTURES

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malais x2 weeks episodes of L hand clumsiness
with a fever

she looks like she is having a TIA

she has HTN

and work up

TB
Lacunar infarct
Cancer
Valvular disease
Stroke/TIA
Pneumonia
Endocarditis
EKG, CBC, Blood cultures (for endocarditis) –> get 2 sets and separate by an hour
CT to check for bleeds
Admit? Empiric abx? (Vancomycin + 3rd gen cephalosporin like ceftriaxone)

blood culture!

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guy in respiratory distress with underlying HTN
high fever
low pulse ox

diaphoretic crackles and confusion with a weak left arm

PACE MAKER PLACED 2 WEEKS AGO

workup

Pneumonia
Endocarditis
Sepsis
PE
EKG, blood cultures, LP, CT head, full set of labs, UA, CXR
Empiric abx
Admit ICU

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how to think to endocarditis

two requirements

something is wrong withe the lining of your heart

transically bacteremic and you seed the thrombus on the end of the valve

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b. Oslerian Scheme Clinical Pathophysiology of infectious endocarditis

i. Active endocardial pathology
ii. Predisposing heart dz
iii. Vascular/embolic phenomena
iv. Persistent bacteremia

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Active endocardial pathology

Vegetation, changing murmur, regurgitant murmur, ECHO findings are now front and center in this diagnosis

When things progress –>Valve destruction, CHF, Myocardial abscess, purulent pericarditis

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Predisposing heart dz

Prosthetic valve, prior IE, congestive heart dz, RHD, etc, MVP w/ regurgitation, PM, AICD

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Vascular/embolic phenomena

common signs

Splenic infarct, etc, CNS infarct,
Osler’s nodes (usually painful see on pads of nails and toes),
Janeway’s lesions (not painful), Splinter hemorrhages under the nails, Roth spots in the eyes, Petechiae

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iv. Persistent bacteremia

Blood cx’s, typical pathogens that causes endocarditis in most causes (usually Staph aureus…others include Strep viridans, enterococcus, fungi)

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(bug + valve —>typical presentation

i. Staph aureus –> tricuspid valve –>

indolent pulmonary sx

IVDU

landing on the right side of the heart due to lower pressure
don’t really need these valves and the manifestations really look like pneumonia

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Staph aureus –> aortic or mitral valve —>

acute/severe cardia

embolic ssx (brain abscess, AMS at the time of presentation)

Acute Bacterial endocarditis
Lethal form, very severe

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Viridens strep., enterococcus –> aortic or mitral valve —>

wimpy pathogen that slowly grows

Classic Subacute endocarditis –>malaise, fever, night sweats

seen with ACD
glomerular nephritis

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Very sticky and good at causing endocarditis but they don’t cause rapid destruction

Janeway lesions and Osler’s nodes noted

w/ this type of endocarditis

viridens enterococcus

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d. Current classification (etiology –>likely bugs… –>antibiotic choice

how frequently do you see community acquired
hospital acquired

i. Native valve (85%)
1. Community acquired 55%
2. Hospital acquired 20%

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bugs for community acquired endocarditis with native valve

a. Staph aureus
b. Strep spp
c. Enterococcus
d. Other

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Hospital acquired bugs in a native valve

a. Staph aureus (MRSA)
b. Coag neg staph
c. Enterococcus
d. Other

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IVDU almost always have this bug

a. Almost always Staph aureus (MRSA)

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prostetic valve bugs

Staph aureus

2. Coag neg Staph

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IE diagnosis: cardinal features

a. Fever –>at the time you come into the ED, 80% of patients are febrile if they don’t it might be because they have been popping tylenol

b. Murmur
c. Bacteremia –> get the blood cultures

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what kind of echo would you do

Can do a transthoracic echo but TEE is really good if you can’t see it on TTE

oscillating mass coming off the leaflet

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this classification criteria quantifies your diagnostic certainty

e. Duke classification – quantifies your diagnostic certainty

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Pulmonary emboli occur when you have

R sided endocarditis (tricuspid)

underlying valve pathology can be

a. Prosthetic valve
b. Prior IE
c. Congestive heart dz
d. RHD, etc
e. Mitral valve prolapse w/ regurgitation

transent bactermia

a. Dental procedure/infection = classic b. Bad teeth c. GU procedure/infection d. IDU

how frequently do you have underlying valve pathology

ii. But in 50% of IE,

left sided endocarditis makes you more or less sick

between mitral and aortic valve which one is worse

aortic valve can cause valve and cardiac failure in hours to days

Hx of having had prosthetic valve or congenital heart dz need to

give you huge dose of amoxicillin

Native valve, no IDU anbx

i. Vancomycin + ceftriaxone

Native valve, IDU anbx

i. Vancomycin

Prosthetic valve, PM, AICD

i. Vancomycin + gentamycin + rifampin

surgical treatment is needed in how many cases what are the indications

50% i. Destroyed valve --> going into hear failure ii. Intracardiac valve abscess

when do you get prophylactic antibiotics

congenital heart dz prosthetic ht valve prior IE cardiac transplant and dental procedure

38 yo man presents to an ambulatory care clinic c/o CP. Pain presents x 24 hours. Severe, sharp, increases with inspiration. Radiates to bilateral trapezius area. + subjective SOB, no n/v/d. No CAD hx. RoS: cough, tactile fevers, chills PE low grade fever with boderline tachycardia

this guys is a mover ``` muscle strain pleurisy pneumonia, MI tension pneumothorax pericarditis PE ```

the schemes of pericarditis

smooth surface on the parietal and visceral side these things are rubbing and are really prone to inflammation think of your knees

what leads to pericarditis

i. Viral/idiopathic ii. Infection/purulent iii. Rheumatologic/CA/post-cardiac injury iv. Uremic lupus is one of those pneumatological diseases

common viral courses of pericarditis

Coxsackieviruses virus

bacterial and infectious causes

s aureus pneumococcus TB fungal

slow fluid accumulation with pericarditis

myocarditis this is seen with arrhythmia heart failure

greater than 2cm of fluid prone to cause

tamponade from effusion this is seen with cancer

1. Myo-pericarditis pathogens -->

Viral (coxsackie), bacterial/purulent

myocarditis presentation

arrhythmias, heart failure, elevated cardiac enzymes

sxs with pericarditis as far as characteristic of pain

better when you lean forward worse when you lean back pain radiating to the traps

two big reasons you get from tamponade

3. Tamponade from trauma usually or mets

pericarditis findings

Chest pain – pleuritic, positional - worse when lying down, relief with leaning forward Pericardial friction rub along with the EKG

EKG findings for pericarditis

widespread ST elevation shaped like a saddle or smile face PR segment depression

(knuckle sign)

PR segment elevation in aVR

Stages of pericarditis -->done over days and weeks

a. Stage 1- come in with pain and you see the addle b. Stage 2 c. Stage 3 – inverted T wave (1-2 weeks) d. Stage 4 – back to normal

cardinal sign of tamponade

a. Muffled heart sounds b. JVD c. Tachycardia d. Hypotension e. Pulsus paradoxus

Pulsus paradoxus

abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration i. Drop in SBP exceeding 10mmHg during inspiration

echo findings with tamponade

i. Equalization of pressures ii. RV impinging on LV during diastole 1-2 cm of fluid

Idiopathic: pericarditis mangement

NSAID + colchicine (prednisone if cannot take NSAID)

Febrile/toxic tx

: admit/consult, blood cx, dx’ic pericardiocentesis (ECHO-guided)

Renal failure tx

– emergent hemodialysis

tamponade tx

– volume loading, emergent pericardiocentesis