Difference between revisions of "Valvular emergencies"

(See Also)
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==
 
==See Also==
Line 21: Line 87:
  
 
==Source==
 
==Source==
10/07 DONALDSON (adapted from Tintinalli, emedicine)
+
Tintinalli
  
 
[[Category:Cards]]
 
[[Category:Cards]]

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)

See Also

Heart Murmurs

Source

Tintinalli