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Endocarditis

• Endocarditis is also known as Infective Bacterial Endocarditis
• The typical presentation includes fever, chills, and malaise associated with a new murmur.
• Subungual hemorrhages, also known as splinter hemorrhages, can occur on the nail bed.
• Petechiae can appear on the palate.
• Osler nodes are painful, violet-colored nodes on the fingers or feet.
• Janeway lesions are nontender, red spots on the palms or soles.
• Roth spots or retinal hemorrhages can be detected on a fundoscopic exam.
• Those with endocarditis need to be referred to the emergency department.

Endocarditis Prophylaxis

• Antibiotic prophylaxis is recommended for high-risk conditions, including a previous history of bacterial endocarditis, prosthetic heart valve, congenital heart disease, and cardiac transplant with abnormal valvular function.
• Invasive procedures that traumatize the oral mucosa, gingiva, or the periapical area of the teeth require prophylaxis.
• Invasive procedures on the respiratory tract require prophylaxis.
• Existing infection present before cystoscopy requires prophylaxis.
• Prophylaxis is no longer given for mitral valve prolapse (MVP) or with gastrointestinal/genitourinary (GI/GU) procedures.

Endocarditis Prophylaxis Medication

• A standard regimen is one hour before the procedure, give Amoxicillin 2 g PO x 1 dose for adults.
• One hour before the procedure, administer 50 mg/kg PO x 1 dose for children.
• For penicillin allergies, alternatives include Clindamycin, azithromycin, clarithromycin (Biaxin), or cephalexin (Keflex).

Deep Vein Thrombosis (DVT)

• Superficial thrombophlebitis involves acute inflammation and clot formation of a superficial vein due to local trauma.
• Risk factors include intravenous drug use, secondary bacterial infection, IV therapy, and trauma.
• Assessment findings include an isolated indurated cord-like vein, warmth, redness, and tenderness along the vein.
• Treatment involves bed rest with elevated extremity, NSAIDs, and antibiotics if secondary to bacterial infection (think S. aureus).
• In cases of sepsis, referral to the emergency department is necessary.
• Deep Vein Thrombosis (DVT) involves the formation of an acute blood clot (thrombi) inside the deep lower extremity or pelvic veins, secondary to specific conditions.
• Stasis, such as prolonged travel by plane or car, immobilization due to surgery, or prolonged bed rest, can lead to DVT.
• Trauma to vessel walls, vascular wall injury, or venous incompetence can contribute to DVT.
• Congestive heart failure and chronic inflammatory states or lifestyle factors can increase the risk.
• Increased coagulation due to inherited coagulation disorders can cause DVT. Ex. Factor C deficiency or Leiden.
• External factors like oral contraceptive use, pregnancy, long bone fractures, trauma, recent surgery, or malignancy are causes of DVT.
• DVT risk factors include obesity, orthopedic surgery, immobility, trauma, pregnancy, oral contraceptive use, malignancy, coagulation deficits, venous catheters, high altitude elevations, polycythemia vera, rheumatoid disease, and lupus.
• Prevention strategies include limiting periods of immobility, prophylactic anticoagulation for associated risk factors, avoiding estrogen-containing oral contraceptives or using low doses, and postsurgical mechanical leg compression.
• Classic presentation involves gradual onset of swelling in the lower leg after a history of travel or prolonged sitting for more than 3 hours, often accompanied by pain, swelling, redness, and warmth in the affected lower extremity.
• Positive Homan's sign: Lower leg pain on dorsiflexion of the foot is part of the assessment.
• Diagnosis is confirmed by ultrasound.
• Hospital admission for heparin IV then warfarin (Coumadin) PO is needed.
• Monitoring of clotting time with CBC, platelets, PT/PTT/INR, D-dimer, chest x-ray, and EKG is essential.
• Single-episode DVT is typically treated for 3 months, but longer treatment may be necessary if recurrent.

Pulmonary Embolus

• Pulmonary Embolus is the same manifestation as DVT. Refer to the emergency department. Mortality rate exceeds 20%.
• Classic presentation: abrupt onset of chest pain, sudden onset of dyspnea, dizziness, syncope and cough
• Other indicators: hemoptysis.
• Assessment includes tachycardia, tachypnea, accentuated S2, pleural friction rub, rales, and pleuritic chest pain.
• Pulmonary CT is highly sensitive. An ECG may show right heart strain.
• Coumadin (Warfarin) is used as maintenance therapy, started in the hospital and overlapping with heparin or Lovenox.
• Dosage is adjusted to maintain an INR of 2 to 3.
• Coumadin is teratogenic and should not be used in pregnant patients but is safe while breastfeeding.
• Vitamin K is the antidote to reverse Coumadin's effect.

Syncope

• Syncope is defined as temporary loss of consciousness, accompanied by fainting and loss of muscle tone.
• Detailed history includes symptoms before and after the event.
• It is important to assess for position changes, prolonged standing, exposure to warm envrionment, and last time having eaten.
• Symptoms can be lightheadedness, diaphoresis, nausea, visual changes before the event.
• Inquire on length of loss of consciousness, seizure activity, height of fall, or any injuries.
• Important to note for confusion or drowsiness after the event.
• Ask for associated cardiac or neuro symptoms: chest pain, diaphoresis, palpitations, headache, diplopia, aphasia, unilateral motor weakness, and paresthesia.
• Important to note incontinence of bladder or bowel.
• Ask about current Meds: vasodilators, beta-blockers, diuretics, anticholinergics.
• Ask about recent drug or medication use and past family history (cardiac, neurologic, seizures).
• Interview family member or witness
• Physical Exam vital signs including orthostatic hypotension
• Perform cardiovascular exam: arrhythmia, murmurs, displaced PMI, bruits, difference in BP between arms including orthostatic pressures
• Perform neurologic exam for focal deficits
• Cardiac-related syncope is associated with a high rate of mortality.
• The common cause of syncope is vasovagal or cardioneurogenic syncope and arrhythmia.
• Arrhythmia includes Sick-sinus syndrome, supraventricular tachycardia, ventricular tachycardia, heart blocks and bradycardia

Sick Sinus Syndrome

• The inability of the heart's natural pacemaker (sinus node) to create a heart rate that's appropriate for the body's needs, causing arrhythmias.
• There are multiple manifestations on electrocardiogram including sinus bradycardia, sinus arrest, sinoatrial, and alternating patterns of bradycardia-tachycardia.

Supraventricular and Ventricular Tachycardia

• Tachycardia is a fast heart rate of more than 100 beats per minute.
• If it begins in the ventricles, it is called ventricular tachycardia.
• If it begins above the ventricles, it is called supraventricular tachycardia.
• SVT is a broad term for tachyarrhythmias originating above the ventricular electrical conduction system (Purkinje fibers).
• Classic paroxysmal SVT has a narrow QRS complex and a regular rhythm.
• Inverted P waves sometimes appear after the QRS complex (retrograde p waves).
• Heart block is abnormal rhythm heartbeats too slowly.
• Electrical signals are blockedbetween the the upper atria and lower ventricals and it is either partially or totally blocked.
• Bradycardia is slower than normal heart rate.
• The hearts of adults at restbeat between 60 and 100 times a minute - less than 60 bpm is considered bradycardia.

Dissecting Abdominal Aortic Aneurysm (AAA)

• This involves severe, sharp, excruciating abdominal, flank, and/or back pain.
• Abdominal pain that that is gnawing, deep, tearing pain.
• Other symptoms: distended abdomen the pulsates with abnormal vital signs and hypotension.
• Risk factors: smoking and htn higher risk.

Acute Myocardial Infarction (MI)

• This is also known as an ST elevation myocardial infarction (STEMI) and acute coronary syndrome (ACS).
• Signs of MI: gradual onset of intense, steady chest discomfort or pain, which may be described as squeezing, tightness, crushing, or heavy pressure.
• May be described as like an elephant sitting on chest or band-like; pain or discomfort may radiate to the left side of the neck, jaw, and left arm or both arms. Pain or discomfort continues at rest and may have diaphoretic with cool, clammy skin.
• Atypical MI symptoms: Women and elderly are more likely to have nonspesific symtoms like shortness of breath or dyspnea, weakness, nausea and vomiting, epigastric pain (may be relate to heartburn), fatgue and syncope May complain of back pain instead of anterior chest pain

AMI ECG Changes

• ST elevation
• T Wave Inversion ST Depression

Kawasaki Disease

• This is also known as Kawasaki Syndrome and Mucocutaneous Lymph Node Syndrome.
• This can be a leading because of an aquired heart disease in children.
• This is an acute, febrile immune-mediated disease of young children characterized by vasculitis that leads to coronary artery aneurysms by causing inflammation of the blood vessels.
• Those that are affected are 2 years old, with 75% younger than 5.
• Boys are 1.5 times more likely than girls to get KD and 25% of the cases consists of older children, adolescents.
• Diagnosis occurs when fever of 101-104F or above for 5 days or longer.
• The symptoms of kawasaki diagnoses are a rash over the torso, especially in the groin area; swollen, red hands and feet.
• Light peeling of the skin on the fingers and toes occurs in the second and third weeks of the illness; bloodshot eyes; swollen lymph glands in the neck (one lymph node measuring more than 1.5 centimeters); redness and swelling of the mouth, lips, throat, and tongue and a strawberry tongue.
• Kawasaki disease is treated in the hospital with intravenous immunoglobulin and aspirin with moderate doses used in the acute phase to help control fever.
• Afterwards, the dose is lowered to help blood clots and is stopped after 4 to 6 weeks if the child has normal coronary dimensions.
• COVID-19 in children may cause multisystem inflammatory syndrome.
• It symptoms is fever, significant abdominal pain, and some features of Kawasaki disease (red eyes, red tongue, swollen hands/feet, rash).

Kawasaki Follow Up

• There are cases that last 4 to 8 weeks but may have some serious sequelae
• There are multiple include aortic dissection, coronary aneurysms, blood clots, heart valve problems from scarring, myocarditis and dysrhythmias.
• Follow up with pediatric cardiologist for several years because effects may not be apparent for years