https://www.wikidoc.org/api.php?action=feedcontributions&feedformat=atom&user=Mohamed+Moubarak wikidoc - User contributions [en] 2026-04-07T00:19:31Z User contributions MediaWiki 1.45.1 https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960830 Mitral stenosis resident survival guide 2014-03-28T14:48:34Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{CMG}}; {{AE}} {{TS}}; {{MM}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''Abbreviations:''' '''AF''': atrial fibrillation; '''PMBC''': percutaneous mitral ballon commissurotomy; '''TR''': tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> <br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;br&gt;<br /> <br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> <br /> :❑ Strength<br /> ::❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> ::❑ Reduced in volume&lt;br&gt;<br /> <br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> <br /> '''Chest examination''':&lt;br&gt;<br /> <br /> '''Auscultation'''<br /> &lt;BR&gt;❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> {{#ev:youtube|HW2pk1icYdM|250}}&lt;br&gt;<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Order tests:'''<br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in leads 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[right atrial enlargement]] or P congenitale<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> [[File:M.S chest X-ray.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Radiopedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Myxoma]]<br /> :❑ Obstruct the mitral orifice<br /> :❑ Exclude with echocardiography<br /> ❑ [[Atrial fibrillation]]<br /> :❑ Order echocardiography to exclude [[mitral stenosis]]<br /> &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960829 Mitral stenosis resident survival guide 2014-03-28T14:47:17Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{CMG}}; {{AE}} {{TS}}; {{MM}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''Abbreviations:''' '''AF''': atrial fibrillation; '''PMBC''': percutaneous mitral ballon commissurotomy; '''TR''': tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> <br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;br&gt;<br /> <br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> <br /> :❑ Strength<br /> ::❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> ::❑ Reduced in volume&lt;br&gt;<br /> <br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> <br /> '''Chest examination''':&lt;br&gt;<br /> <br /> '''Auscultation'''<br /> &lt;BR&gt;❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> {{#ev:youtube|HW2pk1icYdM|250}}&lt;br&gt;<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in leads 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[right atrial enlargement]] or P congenitale<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> [[File:M.S chest X-ray.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Radiopedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Myxoma]]<br /> :❑ Obstruct the mitral orifice<br /> :❑ Exclude with echocardiography<br /> ❑ [[Atrial fibrillation]]<br /> :❑ Order echocardiography to exclude [[mitral stenosis]]<br /> &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960827 Mitral stenosis resident survival guide 2014-03-28T14:46:22Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{CMG}}; {{AE}} {{TS}}; {{MM}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''Abbreviations:''' '''AF''': atrial fibrillation; '''PMBC''': percutaneous mitral ballon commissurotomy; '''TR''': tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> <br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;br&gt;<br /> <br /> :❑ Rhythm&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> <br /> :❑ Strength<br /> ::❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> ::❑ Reduced in volume&lt;br&gt;<br /> <br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> <br /> '''Chest examination''':&lt;br&gt;<br /> <br /> '''Auscultation'''<br /> &lt;BR&gt;❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> {{#ev:youtube|HW2pk1icYdM|250}}&lt;br&gt;<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in leads 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[right atrial enlargement]] or P congenitale<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> [[File:M.S chest X-ray.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Radiopedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Myxoma]]<br /> :❑ Obstruct the mitral orifice<br /> :❑ Exclude with echocardiography<br /> ❑ [[Atrial fibrillation]]<br /> :❑ Order echocardiography to exclude [[mitral stenosis]]<br /> &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960819 Mitral stenosis resident survival guide 2014-03-28T14:34:24Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{CMG}}; {{AE}} {{TS}}; {{MM}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''Abbreviations:''' '''AF''': atrial fibrillation; '''PMBC''': percutaneous mitral ballon commissurotomy; '''TR''': tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> {{#ev:youtube|HW2pk1icYdM|250}}&lt;br&gt;<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in leads 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[right atrial enlargement]] or P congenitale<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> [[File:M.S chest X-ray.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Radiopedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Myxoma]]<br /> :❑ Obstruct the mitral orifice<br /> :❑ Exclude with echocardiography<br /> ❑ [[Atrial fibrillation]]<br /> :❑ Order echocardiography to exclude [[mitral stenosis]]<br /> &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960817 Mitral stenosis resident survival guide 2014-03-28T14:25:20Z <p>Mohamed Moubarak: </p> <hr /> <div>__NOTOC__<br /> <br /> {{CMG}}; {{AE}} {{TS}}; {{MM}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''Abbreviations:''' '''AF''': atrial fibrillation; '''PMBC''': percutaneous mitral ballon commissurotomy; '''TR''': tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> {{#ev:youtube|HW2pk1icYdM|250}}&lt;br&gt;<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> [[File:M.S chest X-ray.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Radiopedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Myxoma]]<br /> :❑ Obstruct the mitral orifice<br /> :❑ Exclude with echocardiography<br /> ❑ [[Atrial fibrillation]]<br /> :❑ Order echocardiography to exclude [[mitral stenosis]]<br /> &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960816 Mitral stenosis resident survival guide 2014-03-28T14:22:58Z <p>Mohamed Moubarak: </p> <hr /> <div>__NOTOC__<br /> <br /> {{CMG}}; {{AE}} {{TS}}; {{MM}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''Abbreviations:''' '''AF''': atrial fibrillation; '''PMBC''': percutaneous mitral ballon commissurotomy; '''TR''': tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> {{#ev:youtube|HW2pk1icYdM|250}}&lt;br&gt;<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> [[File:M.S chest X-ray.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Radiopedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Myxoma]]<br /> :❑ Obstruct the mitral orifice<br /> :❑ Exclude with echocardiography<br /> ❑ [[Atrial fibrillation]]<br /> :❑ Order echocardiography to exclude [[mitral stenosis]]<br /> <br /> &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960815 Mitral stenosis resident survival guide 2014-03-28T14:19:55Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''Abbreviations:''' '''AF''': atrial fibrillation; '''PMBC''': percutaneous mitral ballon commissurotomy; '''TR''': tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> {{#ev:youtube|HW2pk1icYdM|250}}&lt;br&gt;<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> [[File:M.S chest X-ray.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Radiopedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Myxoma]]<br /> :❑ Obstruct the mitral orifice<br /> :❑ Exclude with echocardiography<br /> ❑ [[Atrial fibrillation]]<br /> :❑ Order echocardiography to exclude [[mitral stenosis]]<br /> <br /> &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960814 Mitral stenosis resident survival guide 2014-03-28T14:19:09Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''Abbreviations:''''''AF''': atrial fibrillation; '''PMBC''': percutaneous mitral ballon commissurotomy; '''TR''': tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> {{#ev:youtube|HW2pk1icYdM|250}}&lt;br&gt;<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> [[File:M.S chest X-ray.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Radiopedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Myxoma]]<br /> :❑ Obstruct the mitral orifice<br /> :❑ Exclude with echocardiography<br /> ❑ [[Atrial fibrillation]]<br /> :❑ Order echocardiography to exclude [[mitral stenosis]]<br /> <br /> &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960813 Mitral stenosis resident survival guide 2014-03-28T14:17:49Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> '''Abbreviations:''' &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> {{#ev:youtube|HW2pk1icYdM|250}}&lt;br&gt;<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> [[File:M.S chest X-ray.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Radiopedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Myxoma]]<br /> :❑ Obstruct the mitral orifice<br /> :❑ Exclude with echocardiography<br /> ❑ [[Atrial fibrillation]]<br /> :❑ Order echocardiography to exclude [[mitral stenosis]]<br /> <br /> &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960812 Mitral stenosis resident survival guide 2014-03-28T14:15:01Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> Abbreviations: &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> {{#ev:youtube|HW2pk1icYdM|250}}&lt;br&gt;<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> [[File:M.S chest X-ray.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Radiopedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Myxoma]]<br /> :❑ Obstruct the mitral orifice<br /> :❑ Exclude with echocardiography<br /> ❑ [[Atrial fibrillation]]<br /> :❑ Order echocardiography to exclude [[mitral stenosis]]<br /> <br /> &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960811 Mitral stenosis resident survival guide 2014-03-28T14:14:13Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> {{#ev:youtube|HW2pk1icYdM|250}}&lt;br&gt;<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> [[File:M.S chest X-ray.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Radiopedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Myxoma]]<br /> :❑ Obstruct the mitral orifice<br /> :❑ Exclude with echocardiography<br /> ❑ [[Atrial fibrillation]]<br /> :❑ Order echocardiography to exclude [[mitral stenosis]]<br /> <br /> &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960574 Mitral stenosis resident survival guide 2014-03-27T02:57:30Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> {{#ev:youtube|HW2pk1icYdM|250}}&lt;br&gt;<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> [[File:M.S chest X-ray.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Radiopedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960572 Mitral stenosis resident survival guide 2014-03-27T02:49:52Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> [[File:M.S chest X-ray.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Radiopedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=File:M.S_chest_X-ray.jpg&diff=960571 File:M.S chest X-ray.jpg 2014-03-27T02:48:02Z <p>Mohamed Moubarak: </p> <hr /> <div></div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960569 Mitral stenosis resident survival guide 2014-03-27T02:22:49Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> <br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960567 Mitral stenosis resident survival guide 2014-03-27T02:20:18Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]&lt;br&gt;<br /> <br /> <br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> <br /> ❑ Perform [[transthoracic echocardiography]]<br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960564 Mitral stenosis resident survival guide 2014-03-27T02:08:36Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]<br /> <br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> <br /> :❑ Double right heart border (suggestive of [[left atrial hypertrophy]])<br /> :❑ Prominent pulmonary artery<br /> :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])<br /> <br /> <br /> ❑ Perform [[transthoracic echocardiography]]<br /> <br /> :❑ Assess valve area&lt;br&gt;<br /> :❑ Assess disease of other valves &lt;br&gt;<br /> :❑ Assess mean pressure gradient&lt;br&gt;<br /> :❑ Assess pulmonary artery pressure&lt;br&gt;<br /> :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960562 Mitral stenosis resident survival guide 2014-03-27T01:56:36Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> [[File:De-Rightaxis.jpg|200px]]<br /> <br /> ::❑ [[QRS complex]] is positive in leads III and aVF&lt;br&gt;<br /> ::❑ [[QRS complex]] is negative in leads I and aVL&lt;br&gt;<br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> <br /> :❑ Valve area&lt;br&gt;<br /> :❑ Disease of other valves &lt;br&gt;<br /> :❑ Mean pressure gradient&lt;br&gt;<br /> :❑ Pulmonary artery pressure&lt;br&gt;<br /> :❑ Suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960546 Mitral stenosis resident survival guide 2014-03-27T01:44:19Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> <br /> :❑ Valve area&lt;br&gt;<br /> :❑ Disease of other valves &lt;br&gt;<br /> :❑ Mean pressure gradient&lt;br&gt;<br /> :❑ Pulmonary artery pressure&lt;br&gt;<br /> :❑ Suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960545 Mitral stenosis resident survival guide 2014-03-27T01:42:54Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> ::❑ Absence of [[P waves]]&lt;br&gt;<br /> ::❑ Irregularly irregular [[heart rate]]&lt;br&gt;<br /> [[Image:AFIB_06.jpg|center|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> <br /> :❑ Valve area&lt;br&gt;<br /> :❑ Disease of other valves &lt;br&gt;<br /> :❑ Mean pressure gradient&lt;br&gt;<br /> :❑ Pulmonary artery pressure&lt;br&gt;<br /> :❑ Suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960542 Mitral stenosis resident survival guide 2014-03-27T01:36:27Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> <br /> :❑ Valve area&lt;br&gt;<br /> :❑ Disease of other valves &lt;br&gt;<br /> :❑ Mean pressure gradient&lt;br&gt;<br /> :❑ Pulmonary artery pressure&lt;br&gt;<br /> :❑ Suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960540 Mitral stenosis resident survival guide 2014-03-27T01:30:07Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> <br /> [[Image:E_rvh.jpg|center|300px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> <br /> :❑ Valve area&lt;br&gt;<br /> :❑ Disease of other valves &lt;br&gt;<br /> :❑ Mean pressure gradient&lt;br&gt;<br /> :❑ Pulmonary artery pressure&lt;br&gt;<br /> :❑ Suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960539 Mitral stenosis resident survival guide 2014-03-27T01:26:46Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> ::❑ [[Right axis deviation]] of +90 degrees or more<br /> ::❑ RV1 = 7 mm or more<br /> ::❑ RV1 + SV5 or SV6 = 10 mm or more<br /> ::❑ R/S ratio in V1 = 1.0 or more<br /> ::❑ S/R ratio in V6 = 1.0 or more<br /> ::❑ Late intrinsicoid deflection in V1 (0.035+)<br /> ::❑ Incomplete [[RBBB]] pattern<br /> ::❑ ST T strain pattern in 2,3,aVF<br /> ::❑ [[P pulmonale]] or [[Right atrial enlargement]] or P congenitale<br /> ::❑ S1 S2 S3 pattern in children<br /> ::❑ Tall R wave in V1 or qR in V1<br /> ::❑ R wave greater than S wave in V1<br /> ::❑ R wave progression reversal<br /> ::❑ Inverted [[T wave]] in the anterior precordial leads<br /> <br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> <br /> :❑ Valve area&lt;br&gt;<br /> :❑ Disease of other valves &lt;br&gt;<br /> :❑ Mean pressure gradient&lt;br&gt;<br /> :❑ Pulmonary artery pressure&lt;br&gt;<br /> :❑ Suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960538 Mitral stenosis resident survival guide 2014-03-27T01:19:53Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> &lt;SMALL&gt;''Picture adapted from en.ecgpedia.org''&lt;/SMALL&gt;&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> <br /> :❑ Valve area&lt;br&gt;<br /> :❑ Disease of other valves &lt;br&gt;<br /> :❑ Mean pressure gradient&lt;br&gt;<br /> :❑ Pulmonary artery pressure&lt;br&gt;<br /> :❑ Suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960537 Mitral stenosis resident survival guide 2014-03-27T01:15:34Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]&lt;br&gt;<br /> ::❑ Broad, bifid P wave in lead II (P mitrale)&lt;br&gt;<br /> [[Image:P mitrale.gif|200px]]&lt;br&gt;<br /> ::❑ Biphasic P wave with terminal negative portion&lt;br&gt;<br /> [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]&lt;br&gt;<br /> :❑ [[Right ventricular hypertrophy]]&lt;br&gt;<br /> :❑ [[Right axis deviation]]&lt;br&gt;<br /> :❑ [[Atrial fibrillation]]&lt;br&gt;<br /> <br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> <br /> :❑ Valve area&lt;br&gt;<br /> :❑ Disease of other valves &lt;br&gt;<br /> :❑ Mean pressure gradient&lt;br&gt;<br /> :❑ Pulmonary artery pressure&lt;br&gt;<br /> :❑ Suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960535 Mitral stenosis resident survival guide 2014-03-27T01:02:26Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Order tests:'''<br /> <br /> <br /> ❑ Perform [[EKG]]&lt;br&gt;<br /> ❑ Perform [[chest X-ray]]&lt;br&gt;<br /> ❑ Perform [[transthoracic echocardiography]]<br /> <br /> :❑ Valve area&lt;br&gt;<br /> :❑ Disease of other valves &lt;br&gt;<br /> :❑ Mean pressure gradient&lt;br&gt;<br /> :❑ Pulmonary artery pressure&lt;br&gt;<br /> :❑ Suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt;<br /> &lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960534 Mitral stenosis resident survival guide 2014-03-27T00:51:47Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> <br /> ❑ History of [[rheumatic fever]]&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;❑ Perform [[EKG]]&lt;br&gt;❑ Perform [[chest X-ray]]&lt;br&gt;❑ Perform [[transthoracic echocardiography]]&lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Assess the following on [[TTE]]:'''&lt;br&gt;<br /> ❑ Valve area&lt;br&gt;<br /> ❑ Disease of other valves &lt;br&gt;<br /> ❑ Mean pressure gradient&lt;br&gt;<br /> ❑ Pulmonary artery pressure&lt;br&gt;<br /> ❑ Suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt; &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960533 Mitral stenosis resident survival guide 2014-03-27T00:48:26Z <p>Mohamed Moubarak: /* Overview */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]]. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;❑ Perform [[EKG]]&lt;br&gt;❑ Perform [[chest X-ray]]&lt;br&gt;❑ Perform [[transthoracic echocardiography]]&lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Assess the following on [[TTE]]:'''&lt;br&gt;<br /> ❑ Valve area&lt;br&gt;<br /> ❑ Disease of other valves &lt;br&gt;<br /> ❑ Mean pressure gradient&lt;br&gt;<br /> ❑ Pulmonary artery pressure&lt;br&gt;<br /> ❑ Suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt; &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960526 Mitral stenosis resident survival guide 2014-03-27T00:22:27Z <p>Mohamed Moubarak: </p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]], and development of a pressure gradient between the two chambers. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Diagnosis==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;❑ Perform [[EKG]]&lt;br&gt;❑ Perform [[chest X-ray]]&lt;br&gt;❑ Perform [[transthoracic echocardiography]]&lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Assess the following on [[TTE]]:'''&lt;br&gt;<br /> ❑ Valve area&lt;br&gt;<br /> ❑ Disease of other valves &lt;br&gt;<br /> ❑ Mean pressure gradient&lt;br&gt;<br /> ❑ Pulmonary artery pressure&lt;br&gt;<br /> ❑ Suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt; &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Mitral_stenosis_resident_survival_guide&diff=960521 Mitral stenosis resident survival guide 2014-03-27T00:11:56Z <p>Mohamed Moubarak: /* Management */</p> <hr /> <div>__NOTOC__<br /> <br /> {{WikiDoc CMG}}; {{AE}} {{TS}}<br /> <br /> {{SK}} Mitral valve stenosis; narrowing of mitral valve<br /> <br /> ==Overview==<br /> [[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]], and development of a pressure gradient between the two chambers. The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]]. [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].<br /> <br /> ==Causes==<br /> ===Life Threatening Causes===<br /> Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<br /> * [[Infective endocarditis]]<br /> ===Common Causes===<br /> *[[Congenital]]<br /> *[[Infective endocarditis]]<br /> *[[Mitral annular calcification]]<br /> *[[Rheumatic fever]]&lt;ref name=&quot;Tadele-2013&quot;&gt;{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}&lt;/ref&gt;<br /> ==Initial Evaluation==<br /> Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;.&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''AF''': Atrial fibrillation; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''TR''': Tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': Mitral stenosis &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | A01 |A01=&lt;div style=&quot;float: left; text-align: left; width: 26em; padding:1em;&quot;&gt; '''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Exercise intolerance]]&lt;br&gt;<br /> ❑ [[Dyspnea on exertion]]&lt;br&gt;<br /> ❑ [[Palpitations]]&lt;br&gt;<br /> ❑ [[Orthopnoea]]&lt;br&gt;<br /> ❑ [[Paroxysmal nocturnal dyspnea]]&lt;br&gt;<br /> ❑ [[Hoarseness]]&lt;br&gt;<br /> ❑ [[Cough]]&lt;br&gt;<br /> ❑ [[Hemoptysis]]&lt;br&gt;<br /> ❑ [[Thromboembolism]]&lt;br&gt;<br /> ❑ [[Respiratory infections]]&lt;br&gt;<br /> ❑ [[Fatigue]]&lt;br&gt;<br /> ❑ [[Right heart failure|Right heart failure signs]]:<br /> : ❑ [[Peripheral edema]]&lt;br&gt;<br /> : ❑ [[Ascites]]&lt;br&gt;<br /> : ❑ [[Hepatomegaly]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;br&gt;<br /> '''[[Pulse]]'''&lt;br&gt;<br /> : ❑ [[Tachycardia]]&lt;br&gt;<br /> : ❑ Reduced [[pulse pressure]]&lt;br&gt;<br /> : ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])&lt;br&gt;<br /> : ❑ Reduced in volume&lt;br&gt;<br /> '''Head''':&lt;br&gt;<br /> ❑ Mitral facies&lt;br&gt;<br /> : ❑ Plethoric cheeks with bluish patches&lt;br&gt;<br /> '''Neck''':&lt;br&gt;<br /> ❑ [[Jugular venous distension]]&lt;br&gt;<br /> : ❑ Prominent [[a wave]] in [[right heart failure]]&lt;br&gt;<br /> : ❑ Absent [[a wave]] in [[AF]]&lt;br&gt;<br /> : ❑ Prominent [[v wave]] in [[TR]]&lt;br&gt;<br /> '''Chest''':&lt;br&gt;<br /> ❑ Left parasternal [[heave]]&lt;br&gt;<br /> ❑ Loud [[S1]]&lt;br&gt;<br /> ❑ Loud [[P2]] (indicates [[pulmonary hypertension]])&lt;br&gt;<br /> ❑ Opening snap&lt;br&gt;<br /> ❑ [[Murmur]]&lt;br&gt;<br /> : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)&lt;br&gt;<br /> : ❑ [[Holosystolic murmur]] indicates [[TR]]&lt;br&gt;<br /> : ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]&lt;br&gt;<br /> ❑ [[Rales]]&lt;/div&gt;}}<br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;❑ Perform [[EKG]]&lt;br&gt;❑ Perform [[chest X-ray]]&lt;br&gt;❑ Perform [[transthoracic echocardiography]]&lt;/div&gt;}}<br /> <br /> {{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Assess the following on [[TTE]]:'''&lt;br&gt;<br /> ❑ Valve area&lt;br&gt;<br /> ❑ Disease of other valves &lt;br&gt;<br /> ❑ Mean pressure gradient&lt;br&gt;<br /> ❑ Pulmonary artery pressure&lt;br&gt;<br /> ❑ Suitability of valve morphology for [[PMBV|PMBC]]&lt;br&gt; &lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Management==<br /> The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]]. Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 30em; padding:1em;&quot;&gt; '''Medical therapy'''&lt;br&gt;<br /> ❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ Normal [[sinus rhythm]] and symptoms present on exercise&lt;br&gt;<br /> : ❑ [[AF]] and fast ventricular response&lt;br&gt;<br /> ❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:&lt;br&gt;<br /> : ❑ [[AF]]&lt;br&gt;<br /> : ❑ Prior embolic event&lt;br&gt;<br /> : ❑ [[Left atrial thrombus]] &lt;/div&gt; }}<br /> {{familytree/end}}<br /> <br /> Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.&lt;ref name=&quot;pmid24589852&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589852 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation &lt;/span&gt; &lt;br&gt;<br /> {{familytree/start |summary=PE diagnosis Algorithm.}}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}<br /> {{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}<br /> {{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}<br /> {{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}<br /> {{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}<br /> {{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage D]]&lt;/div&gt;|C03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;|C04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Very severe'''&lt;br&gt;❑ MVA ≤ 1 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 220 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Severe'''&lt;br&gt;❑ MVA ≤ 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;❑ Pressure half time ≥ 150 ms&lt;br&gt;❑ [[Mitral stenosis stages|Stage C]]&lt;/div&gt;|C06=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''Progressive'''&lt;br&gt;❑ MVA &gt; 1.5 cm&lt;sup&gt;2&lt;/sup&gt;&lt;br&gt;Pressure half time &lt; 150 ms &lt;/div&gt;}}<br /> {{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br /> {{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= &lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Perform [[exercise testing]] &lt;/div&gt;|D03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]&lt;/div&gt;|D04=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Assess if the new onset [[AF]] is present&lt;/div&gt;|D05=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Monitor patient periodically&lt;/div&gt;}}<br /> {{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}<br /> {{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}<br /> {{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}<br /> {{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;❑ Proceed with [[PMBV|PMBC]] &lt;/div&gt;|F02=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt; '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''&lt;br&gt;❑ Assess the surgical risk of patient&lt;/div&gt;|F03=&lt;div style=&quot;float: left; text-align: left; width: 8em; padding:1em;&quot;&gt;'''If [[PCWP]] &gt; 25 mm Hg:'''&lt;br&gt; ❑ Proceed with [[PMBV|PMBC]] &lt;br&gt;'''If [[PCWP]]&lt; 25 mm Hg''' :&lt;br&gt;❑ Monitor patient periodically &lt;/div&gt;|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}<br /> {{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}<br /> {{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}<br /> {{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}<br /> {{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Rheumatic Fever Prophylaxis==<br /> Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:&lt;ref name=&quot;pmid24589853&quot;&gt;{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=24589853 }} &lt;/ref&gt;<br /> {| style=&quot;background: #FFFFFF;&quot;<br /> | valign=top |<br /> {| style=&quot;float: left; cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> ! style=&quot;height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);&quot; align=center; colspan=&quot;2&quot;| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | '''''[[Penicillin G benzathine]]''''' ||style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Penicillin V potassium]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''200 mg orally twice a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Sulfadiazine]]''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''1 g orally once a day'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style=&quot;font-size: 90%; padding: 0 5px; background: #DCDCDC&quot; align=left |▸ '''''Varies'''''<br /> |-<br /> |}<br /> |}<br /> &lt;br&gt;<br /> {| style=&quot;cellpadding=0; cellspacing= 0; width: 600px;&quot;<br /> |-<br /> | style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Indications'''|| style=&quot;padding: 0 5px; font-size: 100%; background: #DCDCDC;&quot; align=center | '''Duration of prophylaxis'''<br /> |-<br /> | style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style=&quot;font-size: 90%; padding: 0 5px; background: #F5F5F5&quot; align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''<br /> |-<br /> |}<br /> <br /> ==Do's==<br /> * Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.<br /> * Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.<br /> * Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.<br /> * Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm&lt;sup&gt;2&lt;/sup&gt;) if the patient is undergoing cardiac surgery for other indications.<br /> * Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].<br /> * Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm&lt;sup&gt;2&lt;/sup&gt; .<br /> * Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area &lt; 1 cm&lt;sup&gt;2&lt;/sup&gt;.<br /> * In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Help]]<br /> [[Category:Projects]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Templates]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=960006 Tension pneumothorax resident survival guide 2014-03-25T20:03:48Z <p>Mohamed Moubarak: </p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the contralateral side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm in mechanically ventilated patients&lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] &lt;br&gt;<br /> :❑ [[Chest pain]]<br /> :❑ [[Cough]]<br /> :❑ [[Pleuritic pain]]<br /> :❑ [[Cyanosis]]<br /> :❑ [[Dysphagia]]<br /> :❑ [[Anorexia]]<br /> :❑ [[Dyspnea]]<br /> :❑ [[Fatigue]]<br /> :❑ [[Orthopnea]]<br /> :❑ [[Fever]]<br /> :❑ [[Presyncope|Near syncope]]<br /> :❑ [[Loss of consciousness]]<br /> :❑ [[Cool extremities]]<br /> :❑ [[Peripheral cyanosis]]<br /> :❑ [[Peripheral edema]]<br /> :❑ [[Low urine output]]<br /> <br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | |,|-|^|-|.| | }}<br /> {{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br /> {{familytree | | |!| | | |!| | | | | }}<br /> {{familytree | | M01 | | M02 | |M01=&lt;span style=&quot;color:red&quot;&gt;Proceed with '''immediate''' needle decompression&lt;/span&gt;|M02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; <br /> &lt;span style=&quot;color:red&quot;&gt; Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension&lt;/span&gt; &lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Ensure aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Ensure the site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Confirm the diagnosis by observing instantaneous escape of air &lt;BR&gt;<br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]]<br /> <br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> <br /> ❑ Make sure that the following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> <br /> ❑ Ensure the insertion site&lt;br&gt;<br /> :❑ Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;<br /> ❑ Chest drain is removed after re-expansion of the affected lung&lt;br&gt;<br /> <br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest.<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilation, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24 hours of admission.<br /> *Order chest X-ray before tube removal to confirm reexpansion of the affected lung.<br /> <br /> ==Don'ts==<br /> *Don't remove the needle from the 2nd [[intercostal space]] unless the patient is stable.<br /> *Don't use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don't repeat needle aspiration unless there were technical difficulties.<br /> *Don't leave the chest drain more than 7 days, as it will increase the risk of infection.<br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=960004 Tension pneumothorax resident survival guide 2014-03-25T20:02:54Z <p>Mohamed Moubarak: </p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the contralateral side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm in mechanically ventilated patients&lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] &lt;br&gt;<br /> :❑ [[Chest pain]]<br /> :❑ [[Cough]]<br /> :❑ [[Pleuritic pain]]<br /> :❑ [[Cyanosis]]<br /> :❑ [[Dysphagia]]<br /> :❑ [[Anorexia]]<br /> :❑ [[Dyspnea]]<br /> :❑ [[Fatigue]]<br /> :❑ [[Orthopnea]]<br /> :❑ [[Fever]]<br /> :❑ [[Presyncope|Near syncope]]<br /> :❑ [[Loss of consciousness]]<br /> :❑ [[Cool extremities]]<br /> :❑ [[Peripheral cyanosis]]<br /> :❑ [[Peripheral edema]]<br /> :❑ [[Low urine output]]<br /> <br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | |,|-|^|-|.| | }}<br /> {{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br /> {{familytree | | |!| | | |!| | | | | }}<br /> {{familytree | | M01 | | M02 | |M01=&lt;span style=&quot;color:red&quot;&gt;Proceed with '''immediate''' needle decompression&lt;/span&gt;|M02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; <br /> &lt;span style=&quot;color:red&quot;&gt; Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension&lt;/span&gt; &lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Ensure aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Ensure the site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Confirm the diagnosis by observing instantaneous escape of air &lt;BR&gt;<br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]]<br /> <br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> <br /> ❑ Make sure that the following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> <br /> ❑ Ensure the insertion site&lt;br&gt;<br /> :❑ Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;<br /> ❑ Chest drain is removed after re-expansion of the affected lung&lt;br&gt;<br /> <br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest.<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilation, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24 hours of admission.<br /> *Order chest X-ray before tube removal to confirm reexpansion of the affected lung.<br /> <br /> ==Don'ts==<br /> *Don't remove the needle from the 2nd [[intercostal space]] unless the patient is stable.<br /> *Don't use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> *Don't leave the chest drain more than 7 days, as it will increase the risk of infection.<br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=960002 Tension pneumothorax resident survival guide 2014-03-25T19:59:12Z <p>Mohamed Moubarak: </p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the contralateral side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm in mechanically ventilated patients&lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] &lt;br&gt;<br /> :❑ [[Chest pain]]<br /> :❑ [[Cough]]<br /> :❑ [[Pleuritic pain]]<br /> :❑ [[Cyanosis]]<br /> :❑ [[Dysphagia]]<br /> :❑ [[Anorexia]]<br /> :❑ [[Dyspnea]]<br /> :❑ [[Fatigue]]<br /> :❑ [[Orthopnea]]<br /> :❑ [[Fever]]<br /> :❑ [[Presyncope|Near syncope]]<br /> :❑ [[Loss of consciousness]]<br /> :❑ [[Cool extremities]]<br /> :❑ [[Peripheral cyanosis]]<br /> :❑ [[Peripheral edema]]<br /> :❑ [[Low urine output]]<br /> <br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | |,|-|^|-|.| | }}<br /> {{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br /> {{familytree | | |!| | | |!| | | | | }}<br /> {{familytree | | M01 | | M02 | |M01=&lt;span style=&quot;color:red&quot;&gt;Proceed with '''immediate''' needle decompression&lt;/span&gt;|M02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; <br /> &lt;span style=&quot;color:red&quot;&gt; Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension&lt;/span&gt; &lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Ensure aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Ensure the site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Confirm the diagnosis by observing instantaneous escape of air &lt;BR&gt;<br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]]<br /> <br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> <br /> ❑ Make sure that the following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> <br /> ❑ Ensure the insertion site&lt;br&gt;<br /> :❑ Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;<br /> ❑ Chest drain is removed after re-expansion of the affected lung&lt;br&gt;<br /> <br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest.<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilation, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24 hours of admission.<br /> *Order chest X-ray before tube removal to confirm reexpansion of the affected lung.<br /> <br /> ==Don'ts==<br /> *Don't remove the needle from the 2nd [[intercostal space]] unless the patient is stable.<br /> *Don't use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959992 Tension pneumothorax resident survival guide 2014-03-25T19:40:46Z <p>Mohamed Moubarak: /* Do&#039;s */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the contralateral side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm in mechanically ventilated patients&lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] &lt;br&gt;<br /> :❑ [[Chest pain]]<br /> :❑ [[Cough]]<br /> :❑ [[Pleuritic pain]]<br /> :❑ [[Cyanosis]]<br /> :❑ [[Dysphagia]]<br /> :❑ [[Anorexia]]<br /> :❑ [[Dyspnea]]<br /> :❑ [[Fatigue]]<br /> :❑ [[Orthopnea]]<br /> :❑ [[Fever]]<br /> :❑ [[Presyncope|Near syncope]]<br /> :❑ [[Loss of consciousness]]<br /> :❑ [[Cool extremities]]<br /> :❑ [[Peripheral cyanosis]]<br /> :❑ [[Peripheral edema]]<br /> :❑ [[Low urine output]]<br /> <br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | |,|-|^|-|.| | }}<br /> {{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br /> {{familytree | | |!| | | |!| | | | | }}<br /> {{familytree | | M01 | | M02 | |M01=&lt;span style=&quot;color:red&quot;&gt;Proceed with '''immediate''' needle decompression&lt;/span&gt;|M02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; <br /> &lt;span style=&quot;color:red&quot;&gt; Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension&lt;/span&gt; &lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Ensure aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Ensure the site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Confirm the diagnosis by observing instantaneous escape of air &lt;BR&gt;<br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]]<br /> <br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> <br /> ❑ Make sure that the following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> <br /> ❑ Ensure the insertion site&lt;br&gt;<br /> :❑ Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest.<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilation, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24 hours of admission.<br /> <br /> ==Don'ts==<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959991 Tension pneumothorax resident survival guide 2014-03-25T19:39:48Z <p>Mohamed Moubarak: /* Don&#039;ts */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the contralateral side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm in mechanically ventilated patients&lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] &lt;br&gt;<br /> :❑ [[Chest pain]]<br /> :❑ [[Cough]]<br /> :❑ [[Pleuritic pain]]<br /> :❑ [[Cyanosis]]<br /> :❑ [[Dysphagia]]<br /> :❑ [[Anorexia]]<br /> :❑ [[Dyspnea]]<br /> :❑ [[Fatigue]]<br /> :❑ [[Orthopnea]]<br /> :❑ [[Fever]]<br /> :❑ [[Presyncope|Near syncope]]<br /> :❑ [[Loss of consciousness]]<br /> :❑ [[Cool extremities]]<br /> :❑ [[Peripheral cyanosis]]<br /> :❑ [[Peripheral edema]]<br /> :❑ [[Low urine output]]<br /> <br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | |,|-|^|-|.| | }}<br /> {{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br /> {{familytree | | |!| | | |!| | | | | }}<br /> {{familytree | | M01 | | M02 | |M01=&lt;span style=&quot;color:red&quot;&gt;Proceed with '''immediate''' needle decompression&lt;/span&gt;|M02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; <br /> &lt;span style=&quot;color:red&quot;&gt; Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension&lt;/span&gt; &lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Ensure aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Ensure the site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Confirm the diagnosis by observing instantaneous escape of air &lt;BR&gt;<br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]]<br /> <br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> <br /> ❑ Make sure that the following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> <br /> ❑ Ensure the insertion site&lt;br&gt;<br /> :❑ Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest.<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilation, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24 hours of admission.<br /> <br /> ==Don'ts==<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959989 Tension pneumothorax resident survival guide 2014-03-25T19:37:57Z <p>Mohamed Moubarak: /* Treatment */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the contralateral side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm in mechanically ventilated patients&lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] &lt;br&gt;<br /> :❑ [[Chest pain]]<br /> :❑ [[Cough]]<br /> :❑ [[Pleuritic pain]]<br /> :❑ [[Cyanosis]]<br /> :❑ [[Dysphagia]]<br /> :❑ [[Anorexia]]<br /> :❑ [[Dyspnea]]<br /> :❑ [[Fatigue]]<br /> :❑ [[Orthopnea]]<br /> :❑ [[Fever]]<br /> :❑ [[Presyncope|Near syncope]]<br /> :❑ [[Loss of consciousness]]<br /> :❑ [[Cool extremities]]<br /> :❑ [[Peripheral cyanosis]]<br /> :❑ [[Peripheral edema]]<br /> :❑ [[Low urine output]]<br /> <br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | |,|-|^|-|.| | }}<br /> {{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br /> {{familytree | | |!| | | |!| | | | | }}<br /> {{familytree | | M01 | | M02 | |M01=&lt;span style=&quot;color:red&quot;&gt;Proceed with '''immediate''' needle decompression&lt;/span&gt;|M02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; <br /> &lt;span style=&quot;color:red&quot;&gt; Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension&lt;/span&gt; &lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Ensure aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Ensure the site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Confirm the diagnosis by observing instantaneous escape of air &lt;BR&gt;<br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]]<br /> <br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> <br /> ❑ Make sure that the following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> <br /> ❑ Ensure the insertion site&lt;br&gt;<br /> :❑ Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest.<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilation, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24 hours of admission.<br /> <br /> ==Don'ts==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959986 Tension pneumothorax resident survival guide 2014-03-25T19:35:07Z <p>Mohamed Moubarak: /* Do&#039;s */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the contralateral side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm in mechanically ventilated patients&lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] &lt;br&gt;<br /> :❑ [[Chest pain]]<br /> :❑ [[Cough]]<br /> :❑ [[Pleuritic pain]]<br /> :❑ [[Cyanosis]]<br /> :❑ [[Dysphagia]]<br /> :❑ [[Anorexia]]<br /> :❑ [[Dyspnea]]<br /> :❑ [[Fatigue]]<br /> :❑ [[Orthopnea]]<br /> :❑ [[Fever]]<br /> :❑ [[Presyncope|Near syncope]]<br /> :❑ [[Loss of consciousness]]<br /> :❑ [[Cool extremities]]<br /> :❑ [[Peripheral cyanosis]]<br /> :❑ [[Peripheral edema]]<br /> :❑ [[Low urine output]]<br /> <br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | |,|-|^|-|.| | }}<br /> {{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br /> {{familytree | | |!| | | |!| | | | | }}<br /> {{familytree | | M01 | | M02 | |M01=&lt;span style=&quot;color:red&quot;&gt;Proceed with '''immediate''' needle decompression&lt;/span&gt;|M02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; <br /> &lt;span style=&quot;color:red&quot;&gt; Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension&lt;/span&gt; &lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Ensure aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Ensure the site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Confirm the diagnosis by observing instantaneous escape of air &lt;BR&gt;<br /> &lt;span style=color:red&quot;&gt;Don't repeat needle aspiration unless there were technical difficulties&lt;/span&gt; &lt;br&gt;<br /> &lt;span style=color:red&quot;&gt;Don't remove the cannula, until the chest drain is inserted and is functioning properly&lt;/span&gt; &lt;br&gt;<br /> <br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]]<br /> <br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> <br /> ❑ Make sure that the following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> <br /> ❑ Ensure the insertion site&lt;br&gt;<br /> :❑ Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest.<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilation, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24 hours of admission.<br /> <br /> ==Don'ts==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959984 Tension pneumothorax resident survival guide 2014-03-25T19:28:32Z <p>Mohamed Moubarak: /* Treatment */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the contralateral side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm in mechanically ventilated patients&lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] &lt;br&gt;<br /> :❑ [[Chest pain]]<br /> :❑ [[Cough]]<br /> :❑ [[Pleuritic pain]]<br /> :❑ [[Cyanosis]]<br /> :❑ [[Dysphagia]]<br /> :❑ [[Anorexia]]<br /> :❑ [[Dyspnea]]<br /> :❑ [[Fatigue]]<br /> :❑ [[Orthopnea]]<br /> :❑ [[Fever]]<br /> :❑ [[Presyncope|Near syncope]]<br /> :❑ [[Loss of consciousness]]<br /> :❑ [[Cool extremities]]<br /> :❑ [[Peripheral cyanosis]]<br /> :❑ [[Peripheral edema]]<br /> :❑ [[Low urine output]]<br /> <br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | |,|-|^|-|.| | }}<br /> {{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br /> {{familytree | | |!| | | |!| | | | | }}<br /> {{familytree | | M01 | | M02 | |M01=&lt;span style=&quot;color:red&quot;&gt;Proceed with '''immediate''' needle decompression&lt;/span&gt;|M02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; <br /> &lt;span style=&quot;color:red&quot;&gt; Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension&lt;/span&gt; &lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Ensure aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Ensure the site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Confirm the diagnosis by observing instantaneous escape of air &lt;BR&gt;<br /> &lt;span style=color:red&quot;&gt;Don't repeat needle aspiration unless there were technical difficulties&lt;/span&gt; &lt;br&gt;<br /> &lt;span style=color:red&quot;&gt;Don't remove the cannula, until the chest drain is inserted and is functioning properly&lt;/span&gt; &lt;br&gt;<br /> <br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]]<br /> <br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> <br /> ❑ Make sure that the following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> <br /> ❑ Ensure the insertion site&lt;br&gt;<br /> :❑ Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest<br /> *Differentiate tension pneumothorax from [[pericardial tamponade]], and [[myocardial infarction]].<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Check chest tubes, as they can become plugged or malpositioned and stop functioning.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24h of admission.<br /> <br /> ==Don'ts==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959983 Tension pneumothorax resident survival guide 2014-03-25T19:26:48Z <p>Mohamed Moubarak: /* Treatment */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the contralateral side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm in mechanically ventilated patients&lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] &lt;br&gt;<br /> :❑ [[Chest pain]]<br /> :❑ [[Cough]]<br /> :❑ [[Pleuritic pain]]<br /> :❑ [[Cyanosis]]<br /> :❑ [[Dysphagia]]<br /> :❑ [[Anorexia]]<br /> :❑ [[Dyspnea]]<br /> :❑ [[Fatigue]]<br /> :❑ [[Orthopnea]]<br /> :❑ [[Fever]]<br /> :❑ [[Presyncope|Near syncope]]<br /> :❑ [[Loss of consciousness]]<br /> :❑ [[Cool extremities]]<br /> :❑ [[Peripheral cyanosis]]<br /> :❑ [[Peripheral edema]]<br /> :❑ [[Low urine output]]<br /> <br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | |,|-|^|-|.| | }}<br /> {{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br /> {{familytree | | |!| | | |!| | | | | }}<br /> {{familytree | | M01 | | M02 | |M01=&lt;span style=&quot;color:red&quot;&gt;Proceed with '''immediate''' needle decompression&lt;/span&gt;|M02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; <br /> &lt;span style=&quot;color:red&quot;&gt; Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension&lt;/span&gt; &lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Ensure aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Ensure the site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Confirm the diagnosis by observing instantaneous escape of air &lt;BR&gt;<br /> &lt;span style=color:red&quot;&gt;Don't repeat needle aspiration unless there were technical difficulties&lt;/span&gt; &lt;br&gt;<br /> &lt;span style=color:red&quot;&gt;Don't remove the cannula, until the chest drain is inserted and is functioning properly&lt;/span&gt; &lt;br&gt;<br /> <br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]]<br /> <br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> <br /> ❑ Make sure that following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> <br /> ❑ Ensure the insertion site&lt;br&gt;<br /> :❑ Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest<br /> *Differentiate tension pneumothorax from [[pericardial tamponade]], and [[myocardial infarction]].<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Check chest tubes, as they can become plugged or malpositioned and stop functioning.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24h of admission.<br /> <br /> ==Don'ts==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959978 Tension pneumothorax resident survival guide 2014-03-25T19:17:41Z <p>Mohamed Moubarak: </p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the contralateral side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm in mechanically ventilated patients&lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] &lt;br&gt;<br /> :❑ [[Chest pain]]<br /> :❑ [[Cough]]<br /> :❑ [[Pleuritic pain]]<br /> :❑ [[Cyanosis]]<br /> :❑ [[Dysphagia]]<br /> :❑ [[Anorexia]]<br /> :❑ [[Dyspnea]]<br /> :❑ [[Fatigue]]<br /> :❑ [[Orthopnea]]<br /> :❑ [[Fever]]<br /> :❑ [[Presyncope|Near syncope]]<br /> :❑ [[Loss of consciousness]]<br /> :❑ [[Cool extremities]]<br /> :❑ [[Peripheral cyanosis]]<br /> :❑ [[Peripheral edema]]<br /> :❑ [[Low urine output]]<br /> <br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | |,|-|^|-|.| | }}<br /> {{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br /> {{familytree | | |!| | | |!| | | | | }}<br /> {{familytree | | M01 | | M02 | |M01=&lt;span style=&quot;color:red&quot;&gt;Proceed with '''immediate''' needle decompression&lt;/span&gt;|M02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; <br /> &lt;span style=&quot;color:red&quot;&gt; Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension&lt;/span&gt; &lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;BR&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t repeat needle aspiration unless there were technical difficulties&lt;/span&gt; &lt;br&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t remove the cannula, until the chest drain is inserted and is functioning properly&lt;/span&gt; &lt;br&gt;<br /> <br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]] <br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Make sure that following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ '''Site'''&lt;br&gt;<br /> :❑Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;<br /> <br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Discharge and follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest<br /> *Differentiate tension pneumothorax from [[pericardial tamponade]], and [[myocardial infarction]].<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Check chest tubes, as they can become plugged or malpositioned and stop functioning.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24h of admission.<br /> <br /> ==Don'ts==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959976 Tension pneumothorax resident survival guide 2014-03-25T19:09:23Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the contralateral side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm in mechanically ventilated patients&lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] &lt;br&gt;<br /> :❑ [[Chest pain]]<br /> :❑ [[Cough]]<br /> :❑ [[Pleuritic pain]]<br /> :❑ [[Cyanosis]]<br /> :❑ [[Dysphagia]]<br /> :❑ [[Anorexia]]<br /> :❑ [[Dyspnea]]<br /> :❑ [[Fatigue]]<br /> :❑ [[Orthopnea]]<br /> :❑ [[Fever]]<br /> :❑ [[Presyncope|Near syncope]]<br /> :❑ [[Loss of consciousness]]<br /> :❑ [[Cool extremities]]<br /> :❑ [[Peripheral cyanosis]]<br /> :❑ [[Peripheral edema]]<br /> :❑ [[Low urine output]]<br /> <br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | |,|-|^|-|.| | }}<br /> {{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br /> {{familytree | | |!| | | |!| | | | | }}<br /> {{familytree | | M01 | | M02 | |M02= |M02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; <br /> &lt;span style=&quot;color:red&quot;&gt; Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension&lt;/span&gt; &lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;BR&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t repeat needle aspiration unless there were technical difficulties&lt;/span&gt; &lt;br&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t remove the cannula, until the chest drain is inserted and is functioning properly&lt;/span&gt; &lt;br&gt;<br /> <br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]] <br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Make sure that following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ '''Site'''&lt;br&gt;<br /> :❑Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;<br /> <br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Discharge and follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest<br /> *Differentiate tension pneumothorax from [[pericardial tamponade]], and [[myocardial infarction]].<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Check chest tubes, as they can become plugged or malpositioned and stop functioning.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24h of admission.<br /> <br /> ==Don'ts==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959890 Tension pneumothorax resident survival guide 2014-03-25T16:15:42Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the contralateral side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm in mechanically ventilated patients&lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] &lt;br&gt;<br /> :❑ [[Chest pain]]<br /> :❑ [[Cough]]<br /> :❑ [[Pleuritic pain]]<br /> :❑ [[Cyanosis]]<br /> :❑ [[Dysphagia]]<br /> :❑ [[Anorexia]]<br /> :❑ [[Dyspnea]]<br /> :❑ [[Fatigue]]<br /> :❑ [[Orthopnea]]<br /> :❑ [[Fever]]<br /> :❑ [[Presyncope|Near syncope]]<br /> :❑ [[Loss of consciousness]]<br /> :❑ [[Cool extremities]]<br /> :❑ [[Peripheral cyanosis]]<br /> :❑ [[Peripheral edema]]<br /> :❑ [[Low urine output]]<br /> <br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | J01 | | | | |J01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; &lt;span style=&quot;color:red&quot;&gt; ❑ '''Immediate''' intervention with needle decompression should be done first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Proceed with imaging studies to confirm the diagnosis in a small number of patients who are stable and not in advanced stages of tension&lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> &lt;span style=&quot;color:red&quot;&gt; Don`t order imaging studies unless the patient is stabilized first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;BR&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t repeat needle aspiration unless there were technical difficulties&lt;/span&gt; &lt;br&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t remove the cannula, until the chest drain is inserted and is functioning properly&lt;/span&gt; &lt;br&gt;<br /> <br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]] <br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Make sure that following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ '''Site'''&lt;br&gt;<br /> :❑Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;<br /> <br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Discharge and follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest<br /> *Differentiate tension pneumothorax from [[pericardial tamponade]], and [[myocardial infarction]].<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Check chest tubes, as they can become plugged or malpositioned and stop functioning.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24h of admission.<br /> <br /> ==Don'ts==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959882 Tension pneumothorax resident survival guide 2014-03-25T16:04:10Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the contralateral side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm in mechanically ventilated patients&lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Consider alternative diagnosis:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Pericardial tamponade]] &lt;br&gt;<br /> :❑ [[Anxiety]], [[restlessness]]<br /> :❑ [[Lightheadedness]]<br /> :❑ [[Low blood pressure]]<br /> :❑ [[Palpitations]]<br /> :❑ [[Rapid breathing]]<br /> :❑ [[Shortness of breath]]<br /> :❑ [[Swelling of the abdomen]] or other areas<br /> :❑ [[Syncope]]/[[presyncope]]<br /> :❑ Weak or [[absent pulse]]<br /> :❑ Muffled [[heart sounds]]<br /> :❑ [[Pulsus paradoxus]]<br /> <br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | J01 | | | | |J01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; &lt;span style=&quot;color:red&quot;&gt; ❑ '''Immediate''' intervention with needle decompression should be done first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Proceed with imaging studies to confirm the diagnosis in a small number of patients who are stable and not in advanced stages of tension&lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> &lt;span style=&quot;color:red&quot;&gt; Don`t order imaging studies unless the patient is stabilized first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;BR&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t repeat needle aspiration unless there were technical difficulties&lt;/span&gt; &lt;br&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t remove the cannula, until the chest drain is inserted and is functioning properly&lt;/span&gt; &lt;br&gt;<br /> <br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]] <br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Make sure that following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ '''Site'''&lt;br&gt;<br /> :❑Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;<br /> <br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Discharge and follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest<br /> *Differentiate tension pneumothorax from [[pericardial tamponade]], and [[myocardial infarction]].<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Check chest tubes, as they can become plugged or malpositioned and stop functioning.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24h of admission.<br /> <br /> ==Don'ts==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959872 Tension pneumothorax resident survival guide 2014-03-25T15:52:40Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the contralateral side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm in mechanically ventilated patients&lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Rule out the following alternative diagnosis in uncertain cases:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Pericardial tamponade]] &lt;br&gt;<br /> :❑ Muffled [[heart sounds]]<br /> :❑ [[Pulsus paradoxus]]<br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | J01 | | | | |J01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; &lt;span style=&quot;color:red&quot;&gt; ❑ '''Immediate''' intervention with needle decompression should be done first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Proceed with imaging studies to confirm the diagnosis in a small number of patients who are stable and not in advanced stages of tension&lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> &lt;span style=&quot;color:red&quot;&gt; Don`t order imaging studies unless the patient is stabilized first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;BR&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t repeat needle aspiration unless there were technical difficulties&lt;/span&gt; &lt;br&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t remove the cannula, until the chest drain is inserted and is functioning properly&lt;/span&gt; &lt;br&gt;<br /> <br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]] <br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Make sure that following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ '''Site'''&lt;br&gt;<br /> :❑Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;<br /> <br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Discharge and follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest<br /> *Differentiate tension pneumothorax from [[pericardial tamponade]], and [[myocardial infarction]].<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Check chest tubes, as they can become plugged or malpositioned and stop functioning.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24h of admission.<br /> <br /> ==Don'ts==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959867 Tension pneumothorax resident survival guide 2014-03-25T15:49:28Z <p>Mohamed Moubarak: /* Common Causes */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> * [[Asthma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Emphysema]]<br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the opposite side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm &lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Rule out the following alternative diagnosis in uncertain cases:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Pericardial tamponade]] &lt;br&gt;<br /> :❑ Muffled [[heart sounds]]<br /> :❑ [[Pulsus paradoxus]]<br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | J01 | | | | |J01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; &lt;span style=&quot;color:red&quot;&gt; ❑ '''Immediate''' intervention with needle decompression should be done first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Proceed with imaging studies to confirm the diagnosis in a small number of patients who are stable and not in advanced stages of tension&lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> &lt;span style=&quot;color:red&quot;&gt; Don`t order imaging studies unless the patient is stabilized first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;BR&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t repeat needle aspiration unless there were technical difficulties&lt;/span&gt; &lt;br&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t remove the cannula, until the chest drain is inserted and is functioning properly&lt;/span&gt; &lt;br&gt;<br /> <br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]] <br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Make sure that following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ '''Site'''&lt;br&gt;<br /> :❑Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;<br /> <br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Discharge and follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest<br /> *Differentiate tension pneumothorax from [[pericardial tamponade]], and [[myocardial infarction]].<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Check chest tubes, as they can become plugged or malpositioned and stop functioning.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24h of admission.<br /> <br /> ==Don'ts==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959856 Tension pneumothorax resident survival guide 2014-03-25T15:42:52Z <p>Mohamed Moubarak: /* Overview */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> Tension pneumothorax can be a complication of primary or secondary [[pneumothorax]]. The most common causes of tension pneumothorax are:<br /> <br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Emphysema]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Asthma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the opposite side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm &lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Rule out the following alternative diagnosis in uncertain cases:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Pericardial tamponade]] &lt;br&gt;<br /> :❑ Muffled [[heart sounds]]<br /> :❑ [[Pulsus paradoxus]]<br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | J01 | | | | |J01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; &lt;span style=&quot;color:red&quot;&gt; ❑ '''Immediate''' intervention with needle decompression should be done first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Proceed with imaging studies to confirm the diagnosis in a small number of patients who are stable and not in advanced stages of tension&lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> &lt;span style=&quot;color:red&quot;&gt; Don`t order imaging studies unless the patient is stabilized first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;BR&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t repeat needle aspiration unless there were technical difficulties&lt;/span&gt; &lt;br&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t remove the cannula, until the chest drain is inserted and is functioning properly&lt;/span&gt; &lt;br&gt;<br /> <br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]] <br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Make sure that following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ '''Site'''&lt;br&gt;<br /> :❑Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;<br /> <br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Discharge and follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest<br /> *Differentiate tension pneumothorax from [[pericardial tamponade]], and [[myocardial infarction]].<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Check chest tubes, as they can become plugged or malpositioned and stop functioning.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24h of admission.<br /> <br /> ==Don'ts==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959854 Tension pneumothorax resident survival guide 2014-03-25T15:41:29Z <p>Mohamed Moubarak: </p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; Commonly, the patient presents with severe [[dyspnea]] and [[Chest pain]]. It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> Tension pneumothorax can be a complication of primary or secondary [[pneumothorax]]. The most common causes of tension pneumothorax are:<br /> <br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Emphysema]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Asthma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the opposite side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm &lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Rule out the following alternative diagnosis in uncertain cases:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Pericardial tamponade]] &lt;br&gt;<br /> :❑ Muffled [[heart sounds]]<br /> :❑ [[Pulsus paradoxus]]<br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | J01 | | | | |J01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; &lt;span style=&quot;color:red&quot;&gt; ❑ '''Immediate''' intervention with needle decompression should be done first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Proceed with imaging studies to confirm the diagnosis in a small number of patients who are stable and not in advanced stages of tension&lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> &lt;span style=&quot;color:red&quot;&gt; Don`t order imaging studies unless the patient is stabilized first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;BR&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t repeat needle aspiration unless there were technical difficulties&lt;/span&gt; &lt;br&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t remove the cannula, until the chest drain is inserted and is functioning properly&lt;/span&gt; &lt;br&gt;<br /> <br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]] <br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Make sure that following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ '''Site'''&lt;br&gt;<br /> :❑Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;<br /> <br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Discharge and follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do's==<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest<br /> *Differentiate tension pneumothorax from [[pericardial tamponade]], and [[myocardial infarction]].<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Check chest tubes, as they can become plugged or malpositioned and stop functioning.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24h of admission.<br /> <br /> ==Don'ts==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959755 Tension pneumothorax resident survival guide 2014-03-25T13:31:20Z <p>Mohamed Moubarak: /* Treatment */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> Tension pneumothorax can be a complication of primary or secondary [[pneumothorax]]. The most common causes of tension pneumothorax are:<br /> <br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Emphysema]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Asthma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the opposite side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm &lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Rule out the following alternative diagnosis in uncertain cases:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Pericardial tamponade]] &lt;br&gt;<br /> :❑ Muffled [[heart sounds]]<br /> :❑ [[Pulsus paradoxus]]<br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | J01 | | | | |J01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; &lt;span style=&quot;color:red&quot;&gt; ❑ '''Immediate''' intervention with needle decompression should be done first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Proceed with imaging studies to confirm the diagnosis in a small number of patients who are stable and not in advanced stages of tension&lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> &lt;span style=&quot;color:red&quot;&gt; Don`t order imaging studies unless the patient is stabilized first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;BR&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t repeat needle aspiration unless there were technical difficulties&lt;/span&gt; &lt;br&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t remove the cannula, until the chest drain is inserted and is functioning properly&lt;/span&gt; &lt;br&gt;<br /> <br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]] <br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Make sure that following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ '''Site'''&lt;br&gt;<br /> :❑Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;<br /> <br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Discharge and follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physician&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do`s==<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest<br /> *Differentiate tension pneumothorax from [[pericardial tamponade]], and [[myocardial infarction]].<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Check chest tubes, as they can become plugged or malpositioned and stop functioning.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24h of admission.<br /> <br /> ==Dont`s==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959754 Tension pneumothorax resident survival guide 2014-03-25T13:28:36Z <p>Mohamed Moubarak: /* Treatment */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> Tension pneumothorax can be a complication of primary or secondary [[pneumothorax]]. The most common causes of tension pneumothorax are:<br /> <br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Emphysema]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Asthma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the opposite side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm &lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Rule out the following alternative diagnosis in uncertain cases:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Pericardial tamponade]] &lt;br&gt;<br /> :❑ Muffled [[heart sounds]]<br /> :❑ [[Pulsus paradoxus]]<br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | J01 | | | | |J01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; &lt;span style=&quot;color:red&quot;&gt; ❑ '''Immediate''' intervention with needle decompression should be done first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Proceed with imaging studies to confirm the diagnosis in a small number of patients who are stable and not in advanced stages of tension&lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> &lt;span style=&quot;color:red&quot;&gt; Don`t order imaging studies unless the patient is stabilized first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;BR&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t repeat needle aspiration unless there were technical difficulties&lt;/span&gt; &lt;br&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t remove the cannula, until the chest drain is inserted and is functioning properly&lt;/span&gt; &lt;br&gt;<br /> <br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]] <br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Make sure that following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ '''Site'''&lt;br&gt;<br /> :❑Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;<br /> <br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Discharge and follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physicians&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do`s==<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest<br /> *Differentiate tension pneumothorax from [[pericardial tamponade]], and [[myocardial infarction]].<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Check chest tubes, as they can become plugged or malpositioned and stop functioning.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24h of admission.<br /> <br /> ==Dont`s==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak https://www.wikidoc.org/index.php?title=Tension_pneumothorax_resident_survival_guide&diff=959753 Tension pneumothorax resident survival guide 2014-03-25T13:25:25Z <p>Mohamed Moubarak: /* Diagnosis */</p> <hr /> <div>&lt;div style=&quot;width: 80%;&quot;&gt;<br /> __NOTOC__<br /> {{CMG}}; {{AE}} {{MM}}; {{TS}}<br /> <br /> {{SK}} Collapsed lung; air around the lung; air outside the lung<br /> <br /> {| class=&quot;infobox&quot; style=&quot;margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;&quot; cellpadding=&quot;0&quot; cellspacing=&quot;0&quot;;<br /> |-<br /> ! style=&quot;padding: 0 5px; font-size: 85%; background: #A8A8A8&quot; align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br /> |-<br /> ! style=&quot;font-size: 80%; padding: 0 5px; background: #DCDCDC&quot; align=left | [[Tension pneumothorax resident survival guide#Don'ts|Don'ts]]<br /> |}<br /> <br /> ==Overview==<br /> Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]]. Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]]. This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure. [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt; It should be managed immediately with emergency needle decompression.<br /> <br /> ==Causes==<br /> <br /> ===Life Threatening Causes===<br /> Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.<br /> <br /> ===Common Causes===<br /> Tension pneumothorax can be a complication of primary or secondary [[pneumothorax]]. The most common causes of tension pneumothorax are:<br /> <br /> * [[Mechanical ventilation]]<br /> * [[Trauma]]<br /> * [[Central venous catheter]]<br /> * [[Cardiopulmonary resuscitation]]<br /> * [[Emphysema]]<br /> * [[Chronic obstructive pulmonary disease]]<br /> * [[Asthma]]<br /> <br /> ==Diagnosis==<br /> Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;color:red&quot;&gt;Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.&lt;/span&gt; &lt;br&gt;<br /> <br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography &lt;/span&gt;&lt;br&gt;<br /> {{familytree/start |summary=Diagnostic approach}}<br /> {{familytree | | | |A01 | | | | |A01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Characterize the symptoms:'''&lt;br&gt;<br /> ❑ [[Dyspnea]]&lt;BR&gt;<br /> ❑ [[Chest pain]]&lt;BR&gt;<br /> ❑ [[Cyanosis]]&lt;BR&gt;<br /> ❑ [[Sweating]]&lt;BR&gt;<br /> ❑ [[Anxiety]]&lt;BR&gt;<br /> ❑ [[Fatigue]]&lt;BR&gt;<br /> ❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)&lt;br&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | K01 | | | | | K01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Identify the precipitating factors:'''&lt;br&gt;<br /> ❑ Recent invasive procedures&lt;br&gt;<br /> :❑ [[Thoracentesis]]&lt;br&gt;<br /> :❑ [[Central venous catheter]] insertion&lt;br&gt;<br /> :❑ [[Bronchoscopy]]&lt;br&gt;<br /> :❑ [[Biopsy|Pleural biopsy]]&lt;br&gt;<br /> ❑ [[Mechanical ventilation]]&lt;br&gt;<br /> ❑ [[Cardiopulmonary resuscitation]]&lt;br&gt;<br /> ❑ Presence of [[Drain (surgery)|chest drains]]&lt;br&gt;<br /> ❑ [[Hyperbaric oxygen]] treatment&lt;br&gt;<br /> ❑ [[Trauma|Chest wall trauma]] &lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | }}<br /> {{familytree | | | | B01 | | | | |B01= &lt;div style=&quot;float: Left; text-align: left; width: 30em; padding:1em;&quot;&gt;'''Examine the patient:'''&lt;BR&gt;<br /> '''Appearance of the patient'''&lt;br&gt;<br /> ❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br /> <br /> '''Vital signs'''&lt;BR&gt;<br /> <br /> ❑ [[Pulse]]:&lt;BR&gt;<br /> :❑ Rate<br /> ::❑ [[Tachycardia]]&lt;BR&gt;<br /> :❑ Rhythm&lt;br&gt;<br /> ::❑ Regular<br /> :❑ Strength<br /> ::❑ Weak <br /> ❑ [[Blood pressure]]&lt;BR&gt;<br /> :❑ [[Hypotension]] &lt;BR&gt;<br /> ❑ [[Respiratory rate]]&lt;BR&gt;<br /> :❑ [[Tachypnea]]&lt;BR&gt;<br /> <br /> '''Skin'''&lt;br&gt;<br /> <br /> ❑ [[Cyanosis]]&lt;br&gt;<br /> <br /> '''Neck'''&lt;br&gt;<br /> <br /> ❑ [[Jugular venous distension]] (absent in severe [[hypotension]])&lt;BR&gt;<br /> <br /> '''Respiratory examination:'''&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;BR&gt;<br /> <br /> '''Inspection'''&lt;BR&gt;<br /> ❑ Enlarged involved [[hemithorax]]&lt;BR&gt;<br /> ❑ [[Intercostal space]] widening on the affected [[hemithorax]]&lt;br&gt;<br /> '''Palpation'''&lt;BR&gt;<br /> ❑ Reduced [[lung expansion]] on the affected side &lt;BR&gt;<br /> ❑ [[Trachea]] shifted to the opposite side&lt;BR&gt;<br /> ❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]&lt;BR&gt;<br /> ❑ Displacement of the [[apex beat]]&lt;BR&gt;<br /> '''Percussion'''&lt;BR&gt;<br /> ❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]&lt;BR&gt;<br /> '''Auscultation'''&lt;BR&gt;<br /> ❑ Diminished [[breath sounds]] on the affected side&lt;BR&gt;<br /> <br /> '''Additional findings in ventilated patients:'''&lt;br&gt;<br /> <br /> ❑ Decreased [[oxygen saturation]]&lt;br&gt;<br /> ❑ Increase in inflation pressure &lt;br&gt;<br /> ❑ Increase in [[peak airway pressure]]&lt;br&gt;<br /> ❑ Airway pressure alarm &lt;br&gt;&lt;/div&gt;}}<br /> <br /> {{familytree | | | | |!| | | | | | | | | }}<br /> {{familytree | | | | E01 | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Rule out the following alternative diagnosis in uncertain cases:'''&lt;br&gt;<br /> ❑ [[Acute myocardial infarction]] &lt;br&gt;<br /> :❑ Substernal chest discomfort or chest tightness<br /> ❑ [[Pericardial tamponade]] &lt;br&gt;<br /> :❑ Muffled [[heart sounds]]<br /> :❑ [[Pulsus paradoxus]]<br /> ❑ [[Pulmonary embolism]]&lt;br&gt;<br /> :❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]&lt;br&gt;<br /> :❑ Physical exam is suggestive of [[DVT]]&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | J01 | | | | |J01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; &lt;span style=&quot;color:red&quot;&gt; ❑ '''Immediate''' intervention with needle decompression should be done first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Proceed with imaging studies to confirm the diagnosis in a small number of patients who are stable and not in advanced stages of tension&lt;br&gt;<br /> '''Imaging studies:'''&lt;BR&gt;<br /> &lt;span style=&quot;color:red&quot;&gt; Don`t order imaging studies unless the patient is stabilized first.&lt;/span&gt; &lt;br&gt;<br /> ❑ Perform [[chest X-ray]]&lt;BR&gt;<br /> :❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> [[File:Pneumothorax CXR.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided [[tension pneumothorax]]&lt;BR&gt;<br /> :❑ Air in the [[pleural cavity]]&lt;BR&gt;<br /> :❑ Contralateral deviation of [[mediastinum]]&lt;BR&gt;<br /> :❑ Increased thoracic volume&lt;BR&gt;<br /> :❑ Ipsilateral flattening of heart border&lt;BR&gt;<br /> :❑ Mid diaphragmatic depression&lt;BR&gt;<br /> ❑ Chest CT scanning&lt;BR&gt;<br /> :❑ For uncertain or complex cases<br /> [[File:Pneumothorax CT.jpg|250px]]&lt;BR&gt;<br /> &lt;SMALL&gt;''Picture courtesy of Wikidoc.org''&lt;/SMALL&gt;&lt;br&gt;<br /> Left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).&lt;BR&gt;<br /> ❑ [[Ultrasonography]] (indicated in supine trauma patients)&lt;BR&gt;&lt;/div&gt; |L02=&lt;div style=&quot;float: Left; text-align: left; width: 25em; padding:1em;&quot;&gt;❑ Administer high concentration oxygen&lt;br&gt;<br /> ❑ Perform emergent needle decompression (14-16 G)&lt;br&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;/div&gt;}}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree | | | | | | | | | | | }}<br /> {{familytree/end}}<br /> <br /> ==Treatment==<br /> <br /> Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;&lt;br&gt;<br /> &lt;span style=&quot;font-size:85%&quot;&gt;'''ABC''': Airway, breathing and circulation&lt;/span&gt;&lt;br&gt;{{familytree/start |summary= Treatment}}<br /> {{familytree | | | | C01 | | | | |C01= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Initial supportive measures:'''&lt;BR&gt;<br /> ❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])&lt;BR&gt;<br /> ❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients&lt;BR&gt;<br /> ❑ Administer 100% oxygen &lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;&lt;BR&gt;<br /> ❑ Seek expert consultation (thoracic surgeon)&lt;br&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | |}}<br /> {{familytree | | | | E01 | | | | | | | | | | | | | | E01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt;'''Perform emergency needle decompression:'''<br /> ❑ Aseptic preparation&lt;BR&gt;<br /> :❑ Use alcohol-based skin disinfectants (two applications)&lt;BR&gt;<br /> ❑ Use 14-16 G intravenous cannula&lt;BR&gt;<br /> ❑ Site<br /> :❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)&lt;BR&gt;<br /> :❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }} &lt;/ref&gt;<br /> ❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]&lt;BR&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t repeat needle aspiration unless there were technical difficulties&lt;/span&gt; &lt;br&gt;<br /> &lt;span style=&quot;font-size:85%;color:red&quot;&gt;Don`t remove the cannula, until the chest drain is inserted and is functioning properly&lt;/span&gt; &lt;br&gt;<br /> [[File:Site of needle insertion - 11.jpg|350px]]&lt;BR&gt;<br /> ❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br /> &lt;SMALL&gt;''Video adapted from Youtube.com''&lt;/SMALL&gt;<br /> &lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | | }}<br /> {{familytree | | | | H02 | | | | | | | | | |H02= &lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; ''' Insert chest drain:'''&lt;BR&gt;<br /> ❑ Obtain the [[informed consent]]&lt;BR&gt;<br /> ❑ Insert chest tube immediately after the needle decompression&lt;br&gt;<br /> ❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])&lt;br&gt;<br /> ❑ Use imaging guidance&lt;BR&gt;<br /> :❑ A recent [[chest X-ray]] <br /> ❑ Ensure [[asepsis]]&lt;br&gt;<br /> ❑ Administer adequate analgesics &lt;BR&gt;<br /> ❑ Make sure that following equipments are available:<br /> :❑ 1% [[lignocaine]]<br /> :❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]<br /> :❑ Sterile drapes, gown, gloves<br /> :❑ Needles, syringes, gauze swabs<br /> :❑ Scalpel, suture (0 or 1-0 silk)<br /> :❑ [[Chest tube]] kit<br /> :❑ Closed system drain (including water) and tubing<br /> :❑ Dressing<br /> :❑ Clamp<br /> ❑ '''Site'''&lt;br&gt;<br /> :❑Insert chest tube at the triangle of safety bordered by:&lt;BR&gt;<br /> ::❑ Superiorly: the base of the [[axilla]]&lt;BR&gt;<br /> ::❑ Anteriorly: lateral edge of [[pectoralis major]]&lt;BR&gt;<br /> ::❑ Laterally: lateral edge of [[latissimus dorsi]]&lt;BR&gt;<br /> ::❑ Inferiorly: the line of the [[fifth intercostal space]]&lt;BR&gt;<br /> <br /> [[File:Triangle of safety-11.jpg|400px]]&lt;BR&gt;<br /> <br /> ❑ [[Chest tube|Insert the chest tube]]&lt;br&gt;<br /> ❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)&lt;BR&gt;<br /> ❑ Check chest tubes frequently, as they can become plugged or malpositioned &lt;BR&gt;&lt;/div&gt;}}<br /> {{familytree | | | | |!| | | | | | }}<br /> {{familytree | | | | I01 | | | | | | | | | | | | | | I01=&lt;div style=&quot;float: Left; text-align: left; width: 40em; padding:1em;&quot;&gt; '''Discharge and follow up'''&lt;BR&gt;<br /> ❑ All patients should be followed up by chest physicians&lt;BR&gt;<br /> ❑ Advise to return to hospital if increasing breathlessness develops&lt;BR&gt;<br /> ❑ Advise to avoid air travel&lt;BR&gt;<br /> ❑ Advise to avoid diving &lt;BR&gt;<br /> &lt;/div&gt;}}<br /> {{familytree/end}}<br /> <br /> ==Do`s==<br /> *[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.<br /> *Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.&lt;ref name=&quot;pmid19561940&quot;&gt;{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=19561940 }} &lt;/ref&gt;<br /> *Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system<br /> *Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest<br /> *Differentiate tension pneumothorax from [[pericardial tamponade]], and [[myocardial infarction]].<br /> *Suspect [[tension pneumothorax]] in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.<br /> *Check chest tubes, as they can become plugged or malpositioned and stop functioning.<br /> *Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.<br /> *Refer the patient to respiratory specialist within 24h of admission.<br /> <br /> ==Dont`s==<br /> *Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.<br /> *Don`t use large bore chest drains.&lt;ref name=&quot;pmid20696690&quot;&gt;{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&amp;tool=sumsearch.org/cite&amp;retmode=ref&amp;cmd=prlinks&amp;id=20696690 }}&lt;/ref&gt;<br /> *Don`t repeat needle aspiration unless there were technical difficulties.<br /> <br /> ==References==<br /> {{Reflist|2}}<br /> <br /> [[Category:Disease]]<br /> [[Category:Pulmonology]]<br /> [[Category:Emergency medicine]]<br /> [[Category:Medicine]]<br /> [[Category:Primary care]]<br /> [[Category:Resident survival guide]]<br /> [[Category:Signs and symptoms]]<br /> <br /> {{WikiDoc Help Menu}}<br /> {{WikiDoc Sources}}<br /> &lt;/div&gt;</div> Mohamed Moubarak