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Arbi Ayvazian, DO- Valvular Disease, Conduction Disorders & Bradydysrhythmias- ARMC Emergency Medicine


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Arbi Ayvazian, DO- Valvular Disease, Conduction Disorders & Bradydysrhythmias- ARMC Emergency Medicine

  1. 1. Valvular Disease, Conduction Disorder & Bradydysrhythmias Arbi Ayvazian D.O PGY2 Emergency Medicine ARMC 1/2014
  2. 2. Valvular Disorder
  3. 3. Valvular Disorder  Things to know  Endocarditiis presentation  Murmurs, Rheumatic HD  Specific high risk diseases
  4. 4. Infective Endocarditis  Risk Factors: Abnormal or artificial valve  Mitral valve most common, IVDA -> Tricuspid (staph)  Most common bug -> Staph  Tooth extraction -> Strep  Acute -> high fever, murmur, flu like symp., younger  Subacute -> Strep viridans, Anemia, older  Prophylaxis? Depends on bug and procedure
  5. 5. Infective Endocarditis  Vasculitis and Embolic manifestations  Janeway lesions: Non-tender, hemorrhagic, flat, on palms and soles.  Osler nodes -> tender, tips of fingers and toes  Roth spots and splinter hemorrhages
  6. 6. Infective Endocarditis  Dx by echo, blood cultures, high ESR/CRP  Rx: Vancomycin for Staph, PCN for Strep  Prophylaxis if abnormal valve and procedure  Procedure site determines bug and Abx  Classic broad question -> dental and Amoxicilin, GI/GU more gram negative coverage  Controversial in mitral valve prolapse (no on boards)
  7. 7. End Point of Valve Disease  Heart Fails and dilates  Valves become regurgitant  ECG shows LVH as ventricles expand  LBBB develops as heart and conduction system stretches which is poor prognostic sgin
  8. 8. Murmurs: MR. ASS, MS.AID Mitral Regurgitation Mitral Stenosis Aortic Stenosis Aortic Insufficiency SYSYTOLIC DIASTOLIC
  9. 9. Aortic Stenosis  Symptoms progress from : SOB, CHF, Syncope (bad!)  Murmur: Systolic, up into the neck, slow carotid upstroke  ECG : LVH, LBBB  Exercise-induced syncope  Vasodilators can make it worse  Rx: Surgical (moderate to severe)
  10. 10. Aortic Regurgitation  THINK AORTIC DISECCTION  Murmur: Diastolic, lower left, sternal border  LOTS Signs: water hammer pulse, Austin Flint Murmur, Duroziez’s Murmur, Quincke’s pulse, de Musset’s sign, Lighthouse, Landolfi’s, Beck’s, etc, etc, etc.  Rx: Afterload reduction…..surgical
  11. 11. Mitral Stenosis  Cardiovascular collapse in pregnant patient during delivery  Murmur: Diastolic, Opening SNAP  Atrial fib common, blood backs up into left atrium -> lungs = CHF, Chronic -> Hemoptysis  AF can cause decompensation, crash quick due to loss of KICK, CARDIOVERT if Acute.
  12. 12. Mitral Regurgitaion  Ischemia + SHOCK + new MURMUR = ruptured chordae tendineae/papillary muscle  Murmur: Radiates widely, esp. into axilla  Atrium stretches and produces A. Fib  Mitral valve prolapse can get worse and overtime lead to regurgitation
  13. 13. Conduction Disease  Normal Conduction system
  14. 14. Bundle Branch and Fascicular Blocks  RBBB:  ECD: Wide QRS, Abnormal QRS complexes in right precordical leads (V1- V2) (rSR’). We know this.  Incomplete RBBB  RBBB block morphology with a normal QRS width  Common finding in children and young adult
  15. 15. LBBB  ECG: Wide QRS.  Abnormal morphology: RR’ or large wide R (I, V5, V6) Anormal repol., QS or RS pattern in right precordial leads (V1,V2)
  16. 16. Hemi Blocks  Left anterior vs posterior block  Anterior more common (left coronary blood supply) Ant: left axis deviation, QR (I, aVL), RS (II,III, aVF) Post: Right axis, RS (I, aVL), QR (II,III, aVF)  Bifascicular block  Most common combination: LAF with RBBB  Marker for advance cardiac disease
  17. 17. Heart Blocks  SA node: Blood supply Rt corornary (65%), circumflex (25%), both (10%)  AV node: Post. Descending artery (rt coronary 90%)  SA blocks (sick sinus, sinus pause, sinus arrest, etc.)  Absence of P and ORS, and T cycles  Ventricular activity -> dependent on escape rhythm Rx: pacemaker + medication to suppress tachydysrhythmias
  18. 18. AV node Blocks  First –Degree AV Block – conduction delay in AV node, PR prolong  Second –Degree Block – intermittent loss of conduction between artia and ventricle  Mobitz I (Wenckebach) : PR increases until dropped beat, generally goes not need emergency Tx  Mobitz II: PR normal from beat to beat with an occ. Abrupt dropped beat.  Rx: Can progress to complete block, pacer.  Third-degree AV Block – No conduction through AV  No assos. of P and QRS  Pace and pacemaker
  19. 19. Bradydysrhythmia  Sinus Bradycardia  <60bpm, high vagal tone, medications, hyothyroidism  Signs and symptoms – generally asymptomatic, or signs of hypoperfusion  Rx: Direct towards degree of patient symptoms, atropine, pacing, vasopressors.
  20. 20. Bradydsyrhythmia Simplified! Stable or Unstable? Wide or Narrow? Slow or VERY slow
  21. 21. Bradydysrhythmia  WHY IS THIS PATIENT BRADYCARDIC Ischemia Drugs Electrolytes
  22. 22. Stable or Unstable  Same criteria as tachycardia  BP, mentation, awake and talking? -> perfusion
  23. 23. Wide or Narrow Wide (much worse than narrow) = Block below AV node = Slower = More likely to Stop = NOT atropine sensitive
  24. 24. Wide or Narrow Narrow = more stable = Faster =Atropine sensitive =? Block at AV node
  25. 25. Treatment of Bradycardia IVF, O2, Monitor TCP (often fails) or TVP Atropine (go slow, not good on wide QRS) Epinephrine Dopamine