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Download CARDIAC EMERGENCIES - AJA University of Medical Science
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CARDIAC EMERGENCIES Severe hypertension Systolic BP > 200 mm Hg ◦ Diastolic BP > 120 ◦ If life-threatening organ damage is present, then BP must be reduced quickly to normal levels Rapid BP reductions can cause strokes, renal failure, and myocardial ischemia If life-threatening organ damage is not present, reduce the BP gradually to avoid the side effects Hypertensive Emergencies Most organ damage is from arteriolar necrotizing vasculitis (platelet and fibrin deposition) and loss of autoregulation of the blood vessels The most common cause is discontinuation of BP medication Young patients (<30) or black patients may have secondary causes for HTN, such as renal disease, endocrine syndromes, druginduced catecholamine release, or pregnancy-induced Pathophysiology Encephalopathy Pulmonary edema Renal impairment Retinopathy Aortic dissection Angina/MI Pregnancy related HA, nausea, vomiting, blurred vision, confusion, ◦ seizures, coma stroke ◦ Due to increased afterload, not fluid overload ◦ Decreased glomerular filtration rate, blood/protein in the ◦ urine Due to increased afterload and decreased perfusion ◦ Pre-eclampsia/eclampsia ◦ Clinical Features of HTNinduced organ damage With life-threatening organ damage Close monitoring ◦ Sodium nitroprusside (Nipride) ◦ Arteriovenous dilator Gylceryl trinitrate ◦ Arteriovenous dilator Especially effective when MI/pulm edema co-exist Labetalol ◦ An alpha and beta blocker Can exacerbate asthma, heart failure, heart block Hydralazine and diazoxide ◦ Treatment Without life-threatening organ damage Oral antihypertensives ◦ Sublingual Nifedipine Beta blockers ACE inhibitors Calcium channel blockers Goal is to reduce the diastolic BP to ~100 mm ◦ Hg by 24-48 hours Treatment Infection of the heart valves or endocardium Usually causes a chronic illness but can be acute when due to a virulent organism Causitive organisms Streptococcus viridans: ~50%...poor dentition Staphylococcus aureus: 20-25%...IV drug use Staphylococcus epidermidis: valve replacement surgery Staphylococcus faecalis: 5%...abortion/genitourinary surgery Gram negative organisms: drug addicts/heart valve replacement Fungi: immunosuppressed patient Infective Endocarditis ◦ ◦ ◦ ◦ ◦ ◦ Etiology Most common in elderly people with ◦ degenerative aortic/mitral valve disease Patients with prosthetic valves, rheumatic heart ◦ dx, congenital heart dx Abnormal valves are particularly susceptible ◦ following dental or surgical procedures Infective Endocarditis Clinical Features CNS: embolic infarction, abscesses, meningitis General infection: low grade fever, lethargy, malaise, anemia, wt loss Cardiac: murmurs, heart failure, aneurysms Late signs: clubbing of digits, splenomegaly Joints: arthralgia, septic arthritis Skin: vasculitic rash Soles of feet: Janeway lesion Eyes: retinal hemorrhages Mucosal: subconjunctival hemorrhage Nail bed: splinter hemorrhages, nailfold infarcts Hands: small, red macular lesions, painful swelling of fingers/toes Kidneys: microscopic hematuria, glomerulonephritis Embolic infarcts and abscesses: lungs, kidneys, CNS…loss of peripheral pulses Infective Endocarditis ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Diagnosis Mainly clinical ◦ Confirmed by anemia, raised ESR or CRP, ◦ microscopic hematuria, positive blood cultures, and echocardiography Management ID and treat infection (ATB for ~6 wks) ◦ Surgery to replace infected prosthetic valves ◦ and native valves if infection/heart failure occurs Prognosis Mortality is ~15% ◦ Prophylactic ATB used before procedures in ◦ Infective Endocarditis patients with valvular heart disease Acute pericarditis Due to infection (usually viral), MI, uremia, connective tissue dx, trauma, TB, or neoplasms Clinical features: severe positional (sitting forward relieves) retrosternal chest pain with pericardial rub Diagnosis: concave ST segment elevation…cardiac enzymes may be elevated Management: bed rest, anti-inflammatories, steroids Pericardial Emergencies ◦ ◦ ◦ ◦ Pericardial Effusion Due to infection, uremia, MI, aortic dissection, myxedema, neoplasms, radiotherapy Clinical features: cardiac tamponade reducing CO, SOB, pericarditis, venous congestion that increases with inspiration, hypotension with a paradoxical pulse (BP falls >15 mm Hg during inspiration), distant heart sounds Diagnosis: low voltage EKG, CXR shows cardiomegaly, echocardiography Management: pericardial drainage ◦ ◦ ◦ ◦ Constrictive pericarditis A progressive fibrotic constriction of the pericardium ◦ Surgical removal of the pericardium is the only tx ◦ Pericardial Emergencies
