Valvular emergencies: Difference between revisions

Revision as of 21:52, 15 May 2011

Mitral Stenosis

Most common cause is rheumatic heart dz

Diagnosis

Mid-diastolic murmur
Symptoms
- Exertional dyspnea
- PND
- Acute pulmonary edema
- R-sided HF symptoms
- Hemoptysis (pulm htn > ruptured bronchial vein)
- Precipitants:
  - Anemia
  - Pregnancy
  - Infection
  - A-fib
ECG
- RAD
- Biphasic P waves
CXR
- Straightening of right heart border

Treatment

Diuretics
- Alleviates pulmonary congestion
A-fib treatment
Hemoptysis
- Consider transfusion / surgery consult

Mitral Regurgitation

Chronic
- Most common cause is ischemia/infarction
Acute
- Most common cause is papillary / chordae rupture

Diagnosis

Acute MR
- Suspect if new-onset pulm edema + normal heart size
- Severe dyspnea, tachycardia, pulmonary edema
- Cardiogenic shock may develop
- S4, apical systolic murmur

Treatment

Decrease pulmonary edema
- O2, nitrates, diuretics
Increase forward flow
- Decrease afterload
- Consider nitroprusside in normotensive pts

Aortic Stenosis

Diagnosis

Dyspnea, CP, syncope
- Once symptoms present mean surival is 2-3yr
Late systolic murmur radiating to carotids
Pulsus parvus et tardus
Narrowed pulse pressure

Treatment

Admission
Avoid BBs, CCBs
Avoid afterload reduction
- SV is fixed so could lead to profound hypotension
AS + A-fib = emergency
- AS pts are preload dependent
- Consider emergent cardioversion
Pulm edema
- Diuretics, intubation if necessary
- Caution with use of nitrates/vasodilators

Aortic Regurgitation

Acute AR
Due to:
- Endocarditis
- Aortic dissection
- Blunt chest trauma

Diagnosis

Pulmonary edema
Wide pulse pressure
Dyspnea
Hypotension (may progress to cardiogenic shock)
Diastolic murmur heard immediately after S2
CXR
- Pulmonary edema w/o cardiac enlargement

Treatment

Immediate surgical intervention
Reduce afterload
- Nitroprusside
Diuretics and nitrates don't work
Don't use beta blockers (block compensatory tachycardia)

Source

Tintinalli

Authors:

@@ Line 1: / Line 1: @@
-Symptomatic
+==Mitral Stenosis==
-#Mitral Regurg
+*Most common cause is rheumatic heart dz
-##Rx: reduce afterload (e.g. nitroprusside, NTG)
+===Diagnosis===
-##If 2nd to AMI, Rx: NTG
+*Mid-diastolic murmur
-#Mitral Stenosis
+*Symptoms
-##Rx: rate control if tachy
+**Exertional dyspnea
-##Associated with hemoptysis
+**PND
-##Transfuse + surg
+**Acute pulmonary edema
-#Aortic Regurg
+**R-sided HF symptoms
-##Rx: reduce afterload (e.g. nitroprusside, NTG)
+**Hemoptysis (pulm htn > ruptured bronchial vein)
-#Aortic Stenosis
+**Precipitants:
-##Rx: rate control if tachy
+***Anemia
-##Do not reduce afterload!! (use nitrates very cautiously)
+***Pregnancy
-##Admit if symptomatic (e.g. syncope)
+***Infection
-##+ A.fib = emergency, consider emergent cardioversion
+***A-fib
+*ECG
+**RAD
+**Biphasic P waves
+*CXR
+**Straightening of right heart border
+===Treatment===
+*Diuretics
+**Alleviates pulmonary congestion
+*A-fib treatment
+*Hemoptysis
+**Consider transfusion / surgery consult
-Consider emerg surg for all if primary cause of sx or refractory to Rx
+==Mitral Regurgitation==
+*Chronic
+**Most common cause is ischemia/infarction
+*Acute
+**Most common cause is papillary / chordae rupture
+===Diagnosis===
+*Acute MR
+**Suspect if new-onset pulm edema + normal heart size
+**Severe dyspnea, tachycardia, pulmonary edema
+**Cardiogenic shock may develop
+**S4, apical systolic murmur
+===Treatment===
+*Decrease pulmonary edema
+**O2, nitrates, diuretics
+*Increase forward flow
+**Decrease afterload
+**Consider nitroprusside in normotensive pts
+==Aortic Stenosis==
+===Diagnosis===
+*Dyspnea, CP, syncope
+**Once symptoms present mean surival is 2-3yr
+*Late systolic murmur radiating to carotids
+*Pulsus parvus et tardus
+*Narrowed pulse pressure
+===Treatment===
+*Admission
+*Avoid BBs, CCBs
+*Avoid afterload reduction
+**SV is fixed so could lead to profound hypotension
+*AS + A-fib = emergency
+**AS pts are preload dependent
+**Consider emergent cardioversion
+*Pulm edema
+**Diuretics, intubation if necessary
+**Caution with use of nitrates/vasodilators
+==Aortic Regurgitation==
+*Acute AR
+*Due to:
+**Endocarditis
+**Aortic dissection
+**Blunt chest trauma
+===Diagnosis===
+*Pulmonary edema
+*Wide pulse pressure
+*Dyspnea
+*Hypotension (may progress to cardiogenic shock)
+*Diastolic murmur heard immediately after S2
+*CXR
+**Pulmonary edema w/o cardiac enlargement
+===Treatment===
+*Immediate surgical intervention
+*Reduce afterload
+**Nitroprusside
+*Diuretics and nitrates don't work
+*Don't use beta blockers (block compensatory tachycardia)
 ==See Also==
@@ Line 21: / Line 87: @@
 ==Source==
-/07 DONALDSON (adapted from Tintinalli, emedicine)
+Tintinalli
 [[Category:Cards]]