Rosen & Barkin's 5-Minute Emergency Medicine Consult (755 page)

EKG:

• Mitral stenosis:
  
  • LA enlargement (broad notched P-waves)
    
  • RV hypertrophy
    
  • Right axis deviation
    
  • Atrial fibrillation
    
  • Acute mitral regurgitation:
    
  • Left atrial enlargement
    
  • LVH
    
  • Left axis deviation
    
• Aortic stenosis:
  
  • LVH most common
    
  • Atrial fibrillation
    
  • Interventricular conduction delay
    
  • Complete AV block
    
• Aortic regurgitation:
  
  • Acute = LV strain
    
  • Chronic = LVH and strain
    

See Etiology.

TREATMENT

Avoid vasodilators in aortic stenosis.

• ABCs
  
• Administer oxygen.
  
• Monitor and measure pulse oximetry.
  
• IV access
  

• Mitral stenosis:
  
  • Treat symptoms of CHF.
    
  • Rate control if in atrial fibrillation
    
  • Digoxin
    
  • β-blockers
    
  • Heparin (if new-onset atrial fibrillation)
    
  • Diuretics
    
  • Endocarditis prophylaxis/education
    
• Mitral regurgitation:
  
  • Differentiate between acute and chronic MR:
    
  • Acute:
    
    • Afterload reduction (nitroglycerin, morphine, or sodium nitroprusside)
      
    • Diuresis
      
    • Intra-aortic balloon pump (temporizing for urgent surgery)
      
  • Chronic:
    
    • Diuresis
      
    • Nitrates
      
    • Hydralazine
      
    • ACE inhibitor
      
    • Digoxin
      
    • β-adrenergic blocker (ventricular rate control)
      
    • Calcium antagonist (ventricular rate control)
      
    • Heparin (if atrial fibrillation)
      
    • Endocarditis prophylaxis/education
      
• Aortic stenosis:
  
  • Gentle diuresis if CHF
    
  • Mild hydration if hypotensive and not in CHF
    
  • Avoid nitrates and afterload reduction.
    
  • Digoxin
    
  • Intra-aortic balloon pump (temporize for surgery)
    
  • Endocarditis prophylaxis/education
    
• Aortic regurgitation:
  
  • Chronic:
    
    • Preload and afterload reduction
      
    • Digoxin
      
    • Diuretics
      
    • Endocarditis prophylaxis/education
      
  • Acute:
    
    • Preload and afterload reduction
      
    • Intra-aortic balloon pump
      
    • Urgent surgery
      

• Atenolol: 0.3–2 mg/kg/d PO, max. 2 mg/kg/d (peds: 1–2 mg/kg/dose PO daily suggested)
  
• Digoxin: 0.5 mg bolus IV, then 0.25 mg IV q2h up to 1 mg; 0.125–0.375 mg/d PO
  
• Diltiazem: 0.25 mg/kg IV over 2 min (repeat in 15 min PRN with 0.35 mg/kg) then 5–15 mg/h
  
• Enalapril: 1.25 mg IV q6h; PO 2.5–10 mg BID (peds: 0.1–0.5 mg/kg/d PO div. q12–24h; max.: 0.58 mg/kg/d or 40 mg/d
  
• Esmolol: IV: 500 μg bolus, then 50–400 μg/kg/min
  
• Furosemide: 20–80 mg/d PO/IV/IM; titrate up to 600 mg/d for severe edematous states (peds: 1 mg/kg IV/IM slowly under close supervision; not to exceed 6 mg/kg)
  
• Heparin: 80 U/kg IV bolus, then 18 U/kg/h drip, adjust to maintain partial thromboplastin time 1.5–2 × control (INR 2–3)
  
• Hydralazine: 10–25 mg IV q2–4h (peds: 0.1–0.5 mg/kg IM/IV q4–6h; max. 20 mg/dose)
  
• Metoprolol: 5 mg IV q2min × 3 doses; then 50 mg PO q6h × 48 hr
  
• Nitroglycerin: Start at 20 μg/min IV and titrate to effect (up to 300 μg/min); SL 0.3–0.6 mg PRN; USE NON-PVC tubing. Start at 5 μg/min, titrate up by 5 μg/min every 3–5 min until desired effect. Topical 1/2–2 in of 2% q6h (peds: 0.25–0.5 μg/kg/min IV, increase by 0.5–1 mg/kg/min; max. 20 μg/kg/min)
  
• Phentolamine: 5 mg bolus IV, then 1–2 mg/min IV infusion
  
• Propranolol IV: 1–3 mg at 1 mg/min
  
• Sodium nitroprusside IV: 0.5 μg/kg/min; increase in increments of 0.5 to 1 μg/kg/min q5–10min up to 10 μg/kg/min
  
• Amoxicillin: 2 g PO 1 h before the procedure; alternatively, 3 g PO 1 h before the procedure, followed by 1.5 g PO 6 h after the initial dose:
  
  • Pediatric dose: 50 mg/kg PO 1 h before procedure
    
• Ampicillin: 2 g IV/IM 30 min before the procedure (peds: 50 mg/kg IV/IM 30 min before the procedure)
  
• Clindamycin: 600 mg PO 1 h before procedure (peds: 20 mg/kg PO 1 h before procedure; not to exceed 600 mg)
  

FOLLOW-UP

• New-onset atrial fibrillation
  
• CHF/pulmonary edema
  
• Hemodynamically unstable
  
• Acute mitral or aortic regurgitation
  
• Cardiac ischemia
  
• Angina
  
• Syncope
  
• Arrhythmias
  

• Hemodynamic stability
  
• Unchanged ECG
  
• Resolution of CHF symptoms with diuresis
  
• Chronic mitral regurgitation
  

• For patients who are candidates for outpatient management, close follow-up with a cardiologist to assess severity of valvular disease and need for cardiac surgery
  
• Educate patient about risks of valvular heart disease and need for antibiotic prophylaxis with dental and medical procedures.
  

In patients with chest pain and aortic stenosis, nitrates are contraindicated.

• Bonow RO, Cheitlin MD, Crawford MH, et al. Task Force 3: Valvular heart disease.
  J Am Coll Cardiol
  . 2005;45(8):1334–1340.
  
• Carabello BA, Crawford FA. Valvular heart disease.
  N Engl J Med
  . 1997;337(1):32–41. [Erratum:
  N Engl J Med
  . 1997;337:507].
  
• Chen RS, Bivens MJ, Grossman SA. Diagnosis and management of valvular heart disease in emergency medicine.
  Emerg Med Clin North Am.
  2011;29(4):801–810.
  
• Elkayam U, Bitar F. Valvular heart disease and pregnancy part I: Native valves.
  J Am Coll Cardiol
  . 2005;46:223–230.
  
• Rahimtoola SH. The year in valvular heart disease.
  J Am Coll Cardiol.
  2013;61(12):1290–1301.
  
• Roldan CA, Shively BK, Crawford MH. Value of the cardiovascular examination for detecting valvular heart disease in asymptomatic subjects.
  Am J Cardiol
  . 1996;77:1327–1331.
  

CODES

• 394.0 Mitral stenosis
  
• 424.0 Mitral valve disorders
  
• 424.90 Endocarditis, valve unspecified, unspecified cause
  

BASICS

• Commonly known as chickenpox
  
• Most common in late winter and early spring
  
• Vaccine has reduced incidence by 85%
  
• Adults have a 15 times greater risk for death from varicella than children
  

• DNA virus:
  
  • Latency in cranial nerve ganglia, dorsal root ganglia, and autonomic ganglia with periodic reactivation
    
  • Presents as herpes zoster or shingles decades after primary infection
    
  • Virus is transmitted by respiratory route and direct contact with skin lesions
    
  • Humans are only known reservoir
    

DIAGNOSIS

• Varicella causes a spectrum of disease
  
• Classic childhood illness:
  
  • Usually affects children ages 1–9
    
  • Low-grade fever (100–103°F), headache, malaise, usually precedes rash by 1–2 days
    
  • Pruritus, anorexia, and listlessness
    
  • 10–21 day incubation period
    
  • Infectious from 48 hr before vesicle formation until all vesicles are crusted, typically 3–7 days after onset of rash
    
  • Classic exanthem:
    
    • Lesions begin on the face, spreading to the trunk and extremities
      
    • Papules, vesicles, or pustules, on erythematous base
      
    • Lesions in varying stages of evolution, which is hallmark of Varicella
      
    • “Dewdrop on rose petal”
      
    • Vesicles 2–3 mm in diameter
      
    • Duration of vesicle formation 3–5 days
      
    • May involve conjunctival, oropharyngeal, or vaginal mucosa
      
    • Skin superinfection with group A streptococcus or staphylococcus in 1–4% of healthy children
      
• Adolescents and adults:
  
  • Similar presentation to children but greater risk of severe disease:
    
    • Extracutaneous manifestations in 5–50%, particularly pneumonia
      
• Immunocompromised patients:
  
  • HIV, transplant patients, leukemia patients at highest risk for disseminated form
    
  • Patients on chemotherapy, immunosuppresants, and long-term corticosteroid therapy at high risk
    
  • More numerous lesions that may have hemorrhagic base
    
  • Healing may take longer
    
  • Pneumonia common in these patients
    
• Pregnant patients:
  
  • Prevalent in young expectant women
    
  • More severe disease presentation:
    
    • Risk to fetus greatest in 1st half of pregnancy
      
    • Risk to mother greatest if infection in 2nd half of pregnancy
      
  • Perinatal disease can occur from 5 days predelivery to 48 hr postdelivery
    
• Congenital varicella syndrome
  
• Occasionally follows maternal zoster infection
  
• Limb hypoplasia or paresis
  
• Microcephaly
  
• Ophthalmic lesions
  
• Extracutaneous manifestations:
  
  • Pneumonitis:
    
    • 25 times more common in adults
      
    • Highest risk in adult smokers and immunocompromised children
      
    • Occurs 3–5 days after onset of rash
      
    • Signs: Continued eruption of new lesions, and new-onset cough
      
    • Tachypnea, dyspnea, cyanosis, pleuritic chest pain, and hemoptysis
      
  • Cerebellar ataxia:
    
    • May develop 5 days after rash
      
    • Ataxia, vomiting, slurred speech, fever, vertigo, tremor
      
  • Cerebritis:
    
    • Develops 3–8 days after start of rash
      
    • Duration about 2 wk
      
    • Progressive malaise
      
    • Headache, meningismus, vomiting, fever, delirium, seizures
      
  • Reye syndrome risk