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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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br><br />
<br />
'''Appearance of the patient'''<br><br />
❑ Plethoric cheeks with bluish patches<br><br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<br><br />
<br />
:❑ Rhythm<br><br />
::❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
<br />
:❑ Strength<br />
::❑ Reduced [[pulse pressure]]<br><br />
::❑ Reduced in volume<br><br />
<br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
<br />
'''Chest examination''':<br><br />
<br />
'''Auscultation'''<br />
<BR>❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
{{#ev:youtube|HW2pk1icYdM|250}}<br><br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><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]]<br><br />
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br><br />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ [[Myxoma]]<br />
:❑ Obstruct the mitral orifice<br />
:❑ Exclude with echocardiography<br />
❑ [[Atrial fibrillation]]<br />
:❑ Order echocardiography to exclude [[mitral stenosis]]<br />
</div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br><br />
<br />
'''Appearance of the patient'''<br><br />
❑ Plethoric cheeks with bluish patches<br><br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<br><br />
<br />
:❑ Rhythm<br><br />
::❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
<br />
:❑ Strength<br />
::❑ Reduced [[pulse pressure]]<br><br />
::❑ Reduced in volume<br><br />
<br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
<br />
'''Chest examination''':<br><br />
<br />
'''Auscultation'''<br />
<BR>❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
{{#ev:youtube|HW2pk1icYdM|250}}<br><br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><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]]<br><br />
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br><br />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ [[Myxoma]]<br />
:❑ Obstruct the mitral orifice<br />
:❑ Exclude with echocardiography<br />
❑ [[Atrial fibrillation]]<br />
:❑ Order echocardiography to exclude [[mitral stenosis]]<br />
</div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br><br />
<br />
'''Appearance of the patient'''<br><br />
❑ Plethoric cheeks with bluish patches<br><br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<br><br />
<br />
:❑ Rhythm<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
<br />
:❑ Strength<br />
::❑ Reduced [[pulse pressure]]<br><br />
::❑ Reduced in volume<br><br />
<br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
<br />
'''Chest examination''':<br><br />
<br />
'''Auscultation'''<br />
<BR>❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
{{#ev:youtube|HW2pk1icYdM|250}}<br><br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><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]]<br><br />
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br><br />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ [[Myxoma]]<br />
:❑ Obstruct the mitral orifice<br />
:❑ Exclude with echocardiography<br />
❑ [[Atrial fibrillation]]<br />
:❑ Order echocardiography to exclude [[mitral stenosis]]<br />
</div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
{{#ev:youtube|HW2pk1icYdM|250}}<br><br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><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]]<br><br />
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br><br />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ [[Myxoma]]<br />
:❑ Obstruct the mitral orifice<br />
:❑ Exclude with echocardiography<br />
❑ [[Atrial fibrillation]]<br />
:❑ Order echocardiography to exclude [[mitral stenosis]]<br />
</div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
{{#ev:youtube|HW2pk1icYdM|250}}<br><br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><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]]<br><br />
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br><br />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ [[Myxoma]]<br />
:❑ Obstruct the mitral orifice<br />
:❑ Exclude with echocardiography<br />
❑ [[Atrial fibrillation]]<br />
:❑ Order echocardiography to exclude [[mitral stenosis]]<br />
</div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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{{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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
{{#ev:youtube|HW2pk1icYdM|250}}<br><br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><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]]<br><br />
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br><br />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ [[Myxoma]]<br />
:❑ Obstruct the mitral orifice<br />
:❑ Exclude with echocardiography<br />
❑ [[Atrial fibrillation]]<br />
:❑ Order echocardiography to exclude [[mitral stenosis]]<br />
<br />
</div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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<br />
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{{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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
{{#ev:youtube|HW2pk1icYdM|250}}<br><br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><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]]<br><br />
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br><br />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ [[Myxoma]]<br />
:❑ Obstruct the mitral orifice<br />
:❑ Exclude with echocardiography<br />
❑ [[Atrial fibrillation]]<br />
:❑ Order echocardiography to exclude [[mitral stenosis]]<br />
<br />
</div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
{{#ev:youtube|HW2pk1icYdM|250}}<br><br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><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]]<br><br />
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br><br />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ [[Myxoma]]<br />
:❑ Obstruct the mitral orifice<br />
:❑ Exclude with echocardiography<br />
❑ [[Atrial fibrillation]]<br />
:❑ Order echocardiography to exclude [[mitral stenosis]]<br />
<br />
</div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
'''Abbreviations:''' <span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
{{#ev:youtube|HW2pk1icYdM|250}}<br><br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><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]]<br><br />
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br><br />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ [[Myxoma]]<br />
:❑ Obstruct the mitral orifice<br />
:❑ Exclude with echocardiography<br />
❑ [[Atrial fibrillation]]<br />
:❑ Order echocardiography to exclude [[mitral stenosis]]<br />
<br />
</div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
Abbreviations: <span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
{{#ev:youtube|HW2pk1icYdM|250}}<br><br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><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]]<br><br />
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br><br />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ [[Myxoma]]<br />
:❑ Obstruct the mitral orifice<br />
:❑ Exclude with echocardiography<br />
❑ [[Atrial fibrillation]]<br />
:❑ Order echocardiography to exclude [[mitral stenosis]]<br />
<br />
</div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
{{#ev:youtube|HW2pk1icYdM|250}}<br><br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><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]]<br><br />
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br><br />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ [[Myxoma]]<br />
:❑ Obstruct the mitral orifice<br />
:❑ Exclude with echocardiography<br />
❑ [[Atrial fibrillation]]<br />
:❑ Order echocardiography to exclude [[mitral stenosis]]<br />
<br />
</div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
{{#ev:youtube|HW2pk1icYdM|250}}<br><br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><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]]<br><br />
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br><br />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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{{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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><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]]<br><br />
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br><br />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<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 />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
[[File:De-Rightaxis.jpg|200px]]<br><br />
<br />
<br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<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 />
❑ Perform [[transthoracic echocardiography]]<br />
:❑ Assess valve area<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
[[File:De-Rightaxis.jpg|200px]]<br />
<br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><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<br><br />
:❑ Assess disease of other valves <br><br />
:❑ Assess mean pressure gradient<br><br />
:❑ Assess pulmonary artery pressure<br><br />
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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{{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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
[[File:De-Rightaxis.jpg|200px]]<br />
<br />
::❑ [[QRS complex]] is positive in leads III and aVF<br><br />
::❑ [[QRS complex]] is negative in leads I and aVL<br><br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><br />
❑ Perform [[transthoracic echocardiography]]<br />
<br />
:❑ Valve area<br><br />
:❑ Disease of other valves <br><br />
:❑ Mean pressure gradient<br><br />
:❑ Pulmonary artery pressure<br><br />
:❑ Suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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{{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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><br />
❑ Perform [[transthoracic echocardiography]]<br />
<br />
:❑ Valve area<br><br />
:❑ Disease of other valves <br><br />
:❑ Mean pressure gradient<br><br />
:❑ Pulmonary artery pressure<br><br />
:❑ Suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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<br />
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{{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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
:❑ [[Atrial fibrillation]]<br><br />
::❑ Absence of [[P waves]]<br><br />
::❑ Irregularly irregular [[heart rate]]<br><br />
[[Image:AFIB_06.jpg|center|200px]]<br><br />
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br><br />
<br />
❑ Perform [[chest X-ray]]<br><br />
❑ Perform [[transthoracic echocardiography]]<br />
<br />
:❑ Valve area<br><br />
:❑ Disease of other valves <br><br />
:❑ Mean pressure gradient<br><br />
:❑ Pulmonary artery pressure<br><br />
:❑ Suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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{{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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><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]]<br><br />
:❑ [[Atrial fibrillation]]<br><br />
<br />
❑ Perform [[chest X-ray]]<br><br />
❑ Perform [[transthoracic echocardiography]]<br />
<br />
:❑ Valve area<br><br />
:❑ Disease of other valves <br><br />
:❑ Mean pressure gradient<br><br />
:❑ Pulmonary artery pressure<br><br />
:❑ Suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><br />
<br />
[[Image:E_rvh.jpg|center|300px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><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]]<br><br />
:❑ [[Atrial fibrillation]]<br><br />
<br />
❑ Perform [[chest X-ray]]<br><br />
❑ Perform [[transthoracic echocardiography]]<br />
<br />
:❑ Valve area<br><br />
:❑ Disease of other valves <br><br />
:❑ Mean pressure gradient<br><br />
:❑ Pulmonary artery pressure<br><br />
:❑ Suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<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]]<br><br />
:❑ [[Atrial fibrillation]]<br><br />
<br />
❑ Perform [[chest X-ray]]<br><br />
❑ Perform [[transthoracic echocardiography]]<br />
<br />
:❑ Valve area<br><br />
:❑ Disease of other valves <br><br />
:❑ Mean pressure gradient<br><br />
:❑ Pulmonary artery pressure<br><br />
:❑ Suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br><br />
:❑ [[Right ventricular hypertrophy]]<br><br />
:❑ [[Right axis deviation]]<br><br />
:❑ [[Atrial fibrillation]]<br><br />
<br />
❑ Perform [[chest X-ray]]<br><br />
❑ Perform [[transthoracic echocardiography]]<br />
<br />
:❑ Valve area<br><br />
:❑ Disease of other valves <br><br />
:❑ Mean pressure gradient<br><br />
:❑ Pulmonary artery pressure<br><br />
:❑ Suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br><br />
::❑ Broad, bifid P wave in lead II (P mitrale)<br><br />
[[Image:P mitrale.gif|200px]]<br><br />
::❑ Biphasic P wave with terminal negative portion<br><br />
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br><br />
:❑ [[Right ventricular hypertrophy]]<br><br />
:❑ [[Right axis deviation]]<br><br />
:❑ [[Atrial fibrillation]]<br><br />
<br />
❑ Perform [[chest X-ray]]<br><br />
❑ Perform [[transthoracic echocardiography]]<br />
<br />
:❑ Valve area<br><br />
:❑ Disease of other valves <br><br />
:❑ Mean pressure gradient<br><br />
:❑ Pulmonary artery pressure<br><br />
:❑ Suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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{{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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Order tests:'''<br />
<br />
<br />
❑ Perform [[EKG]]<br><br />
❑ Perform [[chest X-ray]]<br><br />
❑ Perform [[transthoracic echocardiography]]<br />
<br />
:❑ Valve area<br><br />
:❑ Disease of other valves <br><br />
:❑ Mean pressure gradient<br><br />
:❑ Pulmonary artery pressure<br><br />
:❑ Suitability of valve morphology for [[PMBV|PMBC]]<br><br />
</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Consider alternative diagnosis:'''<br><br />
❑ </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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{{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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
<br />
❑ History of [[rheumatic fever]]<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">❑ Perform [[EKG]]<br>❑ Perform [[chest X-ray]]<br>❑ Perform [[transthoracic echocardiography]]</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Assess the following on [[TTE]]:'''<br><br />
❑ Valve area<br><br />
❑ Disease of other valves <br><br />
❑ Mean pressure gradient<br><br />
❑ Pulmonary artery pressure<br><br />
❑ Suitability of valve morphology for [[PMBV|PMBC]]<br> </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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{{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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">❑ Perform [[EKG]]<br>❑ Perform [[chest X-ray]]<br>❑ Perform [[transthoracic echocardiography]]</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Assess the following on [[TTE]]:'''<br><br />
❑ Valve area<br><br />
❑ Disease of other valves <br><br />
❑ Mean pressure gradient<br><br />
❑ Pulmonary artery pressure<br><br />
❑ Suitability of valve morphology for [[PMBV|PMBC]]<br> </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">❑ Perform [[EKG]]<br>❑ Perform [[chest X-ray]]<br>❑ Perform [[transthoracic echocardiography]]</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Assess the following on [[TTE]]:'''<br><br />
❑ Valve area<br><br />
❑ Disease of other valves <br><br />
❑ Mean pressure gradient<br><br />
❑ Pulmonary artery pressure<br><br />
❑ Suitability of valve morphology for [[PMBV|PMBC]]<br> </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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]]<ref name="Tadele-2013">{{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 }}</ref><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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br><br />
<span style="font-size:85%">'''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 </span> <br><br />
{{familytree/start |summary=PE diagnosis Algorithm.}}<br />
{{familytree | | A01 |A01=<div style="float: left; text-align: left; width: 26em; padding:1em;"> '''Characterize the symptoms:'''<br><br />
❑ [[Exercise intolerance]]<br><br />
❑ [[Dyspnea on exertion]]<br><br />
❑ [[Palpitations]]<br><br />
❑ [[Orthopnoea]]<br><br />
❑ [[Paroxysmal nocturnal dyspnea]]<br><br />
❑ [[Hoarseness]]<br><br />
❑ [[Cough]]<br><br />
❑ [[Hemoptysis]]<br><br />
❑ [[Thromboembolism]]<br><br />
❑ [[Respiratory infections]]<br><br />
❑ [[Fatigue]]<br><br />
❑ [[Right heart failure|Right heart failure signs]]:<br />
: ❑ [[Peripheral edema]]<br><br />
: ❑ [[Ascites]]<br><br />
: ❑ [[Hepatomegaly]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br><br />
'''[[Pulse]]'''<br><br />
: ❑ [[Tachycardia]]<br><br />
: ❑ Reduced [[pulse pressure]]<br><br />
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br><br />
: ❑ Reduced in volume<br><br />
'''Head''':<br><br />
❑ Mitral facies<br><br />
: ❑ Plethoric cheeks with bluish patches<br><br />
'''Neck''':<br><br />
❑ [[Jugular venous distension]]<br><br />
: ❑ Prominent [[a wave]] in [[right heart failure]]<br><br />
: ❑ Absent [[a wave]] in [[AF]]<br><br />
: ❑ Prominent [[v wave]] in [[TR]]<br><br />
'''Chest''':<br><br />
❑ Left parasternal [[heave]]<br><br />
❑ Loud [[S1]]<br><br />
❑ Loud [[P2]] (indicates [[pulmonary hypertension]])<br><br />
❑ Opening snap<br><br />
❑ [[Murmur]]<br><br />
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br><br />
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br><br />
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br><br />
❑ [[Rales]]</div>}}<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 30em; padding:1em;">❑ Perform [[EKG]]<br>❑ Perform [[chest X-ray]]<br>❑ Perform [[transthoracic echocardiography]]</div>}}<br />
<br />
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}<br />
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Assess the following on [[TTE]]:'''<br><br />
❑ Valve area<br><br />
❑ Disease of other valves <br><br />
❑ Mean pressure gradient<br><br />
❑ Pulmonary artery pressure<br><br />
❑ Suitability of valve morphology for [[PMBV|PMBC]]<br> </div>}}<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=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br><br />
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br><br />
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br><br />
: ❑ [[AF]] and fast ventricular response<br><br />
❑ Consider [[anticoagulation therapy]] in [[MS]] patients with:<br><br />
: ❑ [[AF]]<br><br />
: ❑ Prior embolic event<br><br />
: ❑ [[Left atrial thrombus]] </div> }}<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.<ref name="pmid24589852">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br><br />
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br><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=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}<br />
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}<br />
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}<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=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically </div>|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:<ref name="pmid24589853">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853 }} </ref><br />
{| style="background: #FFFFFF;"<br />
| valign=top |<br />
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"<br />
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''<br />
|-<br />
|}<br />
|}<br />
<br><br />
{| style="cellpadding=0; cellspacing= 0; width: 600px;"<br />
|-<br />
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''<br />
|-<br />
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''<br />
|-<br />
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" 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<sup>2</sup>) 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<sup>2</sup> .<br />
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.<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 />
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{{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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the contralateral side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br><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]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | |,|-|^|-|.| | }}<br />
{{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br />
{{familytree | | |!| | | |!| | | | | }}<br />
{{familytree | | M01 | | M02 | |M01=<span style="color:red">Proceed with '''immediate''' needle decompression</span>|M02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> <br />
<span style="color:red"> Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension</span> <br><br />
'''Imaging studies:'''<BR><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Ensure aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Ensure the site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Confirm the diagnosis by observing instantaneous escape of air <BR><br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]]<br />
<br />
❑ Administer adequate analgesics <BR><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]])<br><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]]<br><br />
<br />
❑ Ensure the insertion site<br><br />
:❑ Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR>❑ Insert chest tube immediately after the needle decompression<br><br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR><br />
❑ Chest drain is removed after re-expansion of the affected lung<br><br />
<br />
</div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the contralateral side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br><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]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | |,|-|^|-|.| | }}<br />
{{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br />
{{familytree | | |!| | | |!| | | | | }}<br />
{{familytree | | M01 | | M02 | |M01=<span style="color:red">Proceed with '''immediate''' needle decompression</span>|M02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> <br />
<span style="color:red"> Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension</span> <br><br />
'''Imaging studies:'''<BR><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Ensure aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Ensure the site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Confirm the diagnosis by observing instantaneous escape of air <BR><br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]]<br />
<br />
❑ Administer adequate analgesics <BR><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]])<br><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]]<br><br />
<br />
❑ Ensure the insertion site<br><br />
:❑ Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR>❑ Insert chest tube immediately after the needle decompression<br><br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR><br />
❑ Chest drain is removed after re-expansion of the affected lung<br><br />
<br />
</div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the contralateral side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br><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]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | |,|-|^|-|.| | }}<br />
{{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br />
{{familytree | | |!| | | |!| | | | | }}<br />
{{familytree | | M01 | | M02 | |M01=<span style="color:red">Proceed with '''immediate''' needle decompression</span>|M02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> <br />
<span style="color:red"> Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension</span> <br><br />
'''Imaging studies:'''<BR><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Ensure aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Ensure the site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Confirm the diagnosis by observing instantaneous escape of air <BR><br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]]<br />
<br />
❑ Administer adequate analgesics <BR><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]])<br><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]]<br><br />
<br />
❑ Ensure the insertion site<br><br />
:❑ Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR>❑ Insert chest tube immediately after the needle decompression<br><br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR><br />
❑ Chest drain is removed after re-expansion of the affected lung<br><br />
<br />
</div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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's */</p>
<hr />
<div><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the contralateral side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br><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]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | |,|-|^|-|.| | }}<br />
{{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br />
{{familytree | | |!| | | |!| | | | | }}<br />
{{familytree | | M01 | | M02 | |M01=<span style="color:red">Proceed with '''immediate''' needle decompression</span>|M02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> <br />
<span style="color:red"> Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension</span> <br><br />
'''Imaging studies:'''<BR><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Ensure aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Ensure the site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Confirm the diagnosis by observing instantaneous escape of air <BR><br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]]<br />
<br />
❑ Administer adequate analgesics <BR><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]])<br><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]]<br><br />
<br />
❑ Ensure the insertion site<br><br />
:❑ Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR>❑ Insert chest tube immediately after the needle decompression<br><br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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'ts */</p>
<hr />
<div><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the contralateral side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br><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]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | |,|-|^|-|.| | }}<br />
{{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br />
{{familytree | | |!| | | |!| | | | | }}<br />
{{familytree | | M01 | | M02 | |M01=<span style="color:red">Proceed with '''immediate''' needle decompression</span>|M02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> <br />
<span style="color:red"> Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension</span> <br><br />
'''Imaging studies:'''<BR><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Ensure aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Ensure the site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Confirm the diagnosis by observing instantaneous escape of air <BR><br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]]<br />
<br />
❑ Administer adequate analgesics <BR><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]])<br><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]]<br><br />
<br />
❑ Ensure the insertion site<br><br />
:❑ Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR>❑ Insert chest tube immediately after the needle decompression<br><br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the contralateral side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br><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]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | |,|-|^|-|.| | }}<br />
{{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br />
{{familytree | | |!| | | |!| | | | | }}<br />
{{familytree | | M01 | | M02 | |M01=<span style="color:red">Proceed with '''immediate''' needle decompression</span>|M02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> <br />
<span style="color:red"> Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension</span> <br><br />
'''Imaging studies:'''<BR><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Ensure aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Ensure the site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Confirm the diagnosis by observing instantaneous escape of air <BR><br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]]<br />
<br />
❑ Administer adequate analgesics <BR><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]])<br><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]]<br><br />
<br />
❑ Ensure the insertion site<br><br />
:❑ Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR>❑ Insert chest tube immediately after the needle decompression<br><br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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's */</p>
<hr />
<div><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the contralateral side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br><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]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | |,|-|^|-|.| | }}<br />
{{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br />
{{familytree | | |!| | | |!| | | | | }}<br />
{{familytree | | M01 | | M02 | |M01=<span style="color:red">Proceed with '''immediate''' needle decompression</span>|M02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> <br />
<span style="color:red"> Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension</span> <br><br />
'''Imaging studies:'''<BR><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Ensure aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Ensure the site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Confirm the diagnosis by observing instantaneous escape of air <BR><br />
<span style=color:red">Don't repeat needle aspiration unless there were technical difficulties</span> <br><br />
<span style=color:red">Don't remove the cannula, until the chest drain is inserted and is functioning properly</span> <br><br />
<br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]]<br />
<br />
❑ Administer adequate analgesics <BR><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]])<br><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]]<br><br />
<br />
❑ Ensure the insertion site<br><br />
:❑ Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR>❑ Insert chest tube immediately after the needle decompression<br><br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the contralateral side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br><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]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | |,|-|^|-|.| | }}<br />
{{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br />
{{familytree | | |!| | | |!| | | | | }}<br />
{{familytree | | M01 | | M02 | |M01=<span style="color:red">Proceed with '''immediate''' needle decompression</span>|M02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> <br />
<span style="color:red"> Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension</span> <br><br />
'''Imaging studies:'''<BR><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Ensure aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Ensure the site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Confirm the diagnosis by observing instantaneous escape of air <BR><br />
<span style=color:red">Don't repeat needle aspiration unless there were technical difficulties</span> <br><br />
<span style=color:red">Don't remove the cannula, until the chest drain is inserted and is functioning properly</span> <br><br />
<br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]]<br />
<br />
❑ Administer adequate analgesics <BR><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]])<br><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]]<br><br />
<br />
❑ Ensure the insertion site<br><br />
:❑ Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR>❑ Insert chest tube immediately after the needle decompression<br><br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the contralateral side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br><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]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | |,|-|^|-|.| | }}<br />
{{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br />
{{familytree | | |!| | | |!| | | | | }}<br />
{{familytree | | M01 | | M02 | |M01=<span style="color:red">Proceed with '''immediate''' needle decompression</span>|M02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> <br />
<span style="color:red"> Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension</span> <br><br />
'''Imaging studies:'''<BR><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Ensure aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Ensure the site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Confirm the diagnosis by observing instantaneous escape of air <BR><br />
<span style=color:red">Don't repeat needle aspiration unless there were technical difficulties</span> <br><br />
<span style=color:red">Don't remove the cannula, until the chest drain is inserted and is functioning properly</span> <br><br />
<br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]]<br />
<br />
❑ Administer adequate analgesics <BR><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]])<br><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]]<br><br />
<br />
❑ Ensure the insertion site<br><br />
:❑ Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR>❑ Insert chest tube immediately after the needle decompression<br><br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the contralateral side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br><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]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | |,|-|^|-|.| | }}<br />
{{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br />
{{familytree | | |!| | | |!| | | | | }}<br />
{{familytree | | M01 | | M02 | |M01=<span style="color:red">Proceed with '''immediate''' needle decompression</span>|M02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> <br />
<span style="color:red"> Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension</span> <br><br />
'''Imaging studies:'''<BR><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]<BR><br />
<span style="font-size:85%;color:red">Don`t repeat needle aspiration unless there were technical difficulties</span> <br><br />
<span style="font-size:85%;color:red">Don`t remove the cannula, until the chest drain is inserted and is functioning properly</span> <br><br />
<br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Insert chest tube immediately after the needle decompression<br><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]])<br><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]] <br />
❑ Ensure [[asepsis]]<br><br />
❑ Administer adequate analgesics <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 />
❑ '''Site'''<br><br />
:❑Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR><br />
<br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Discharge and follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the contralateral side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br><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]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | |,|-|^|-|.| | }}<br />
{{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}<br />
{{familytree | | |!| | | |!| | | | | }}<br />
{{familytree | | M01 | | M02 | |M02= |M02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> <br />
<span style="color:red"> Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension</span> <br><br />
'''Imaging studies:'''<BR><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]<BR><br />
<span style="font-size:85%;color:red">Don`t repeat needle aspiration unless there were technical difficulties</span> <br><br />
<span style="font-size:85%;color:red">Don`t remove the cannula, until the chest drain is inserted and is functioning properly</span> <br><br />
<br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Insert chest tube immediately after the needle decompression<br><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]])<br><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]] <br />
❑ Ensure [[asepsis]]<br><br />
❑ Administer adequate analgesics <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 />
❑ '''Site'''<br><br />
:❑Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR><br />
<br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Discharge and follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the contralateral side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br><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]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | J01 | | | | |J01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> <span style="color:red"> ❑ '''Immediate''' intervention with needle decompression should be done first.</span> <br><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<br><br />
'''Imaging studies:'''<BR><br />
<span style="color:red"> Don`t order imaging studies unless the patient is stabilized first.</span> <br><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]<BR><br />
<span style="font-size:85%;color:red">Don`t repeat needle aspiration unless there were technical difficulties</span> <br><br />
<span style="font-size:85%;color:red">Don`t remove the cannula, until the chest drain is inserted and is functioning properly</span> <br><br />
<br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Insert chest tube immediately after the needle decompression<br><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]])<br><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]] <br />
❑ Ensure [[asepsis]]<br><br />
❑ Administer adequate analgesics <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 />
❑ '''Site'''<br><br />
:❑Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR><br />
<br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Discharge and follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the contralateral side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Pericardial tamponade]] <br><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]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | J01 | | | | |J01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> <span style="color:red"> ❑ '''Immediate''' intervention with needle decompression should be done first.</span> <br><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<br><br />
'''Imaging studies:'''<BR><br />
<span style="color:red"> Don`t order imaging studies unless the patient is stabilized first.</span> <br><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]<BR><br />
<span style="font-size:85%;color:red">Don`t repeat needle aspiration unless there were technical difficulties</span> <br><br />
<span style="font-size:85%;color:red">Don`t remove the cannula, until the chest drain is inserted and is functioning properly</span> <br><br />
<br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Insert chest tube immediately after the needle decompression<br><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]])<br><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]] <br />
❑ Ensure [[asepsis]]<br><br />
❑ Administer adequate analgesics <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 />
❑ '''Site'''<br><br />
:❑Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR><br />
<br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Discharge and follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the contralateral side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Rule out the following alternative diagnosis in uncertain cases:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Pericardial tamponade]] <br><br />
:❑ Muffled [[heart sounds]]<br />
:❑ [[Pulsus paradoxus]]<br />
❑ [[Pulmonary embolism]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | J01 | | | | |J01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> <span style="color:red"> ❑ '''Immediate''' intervention with needle decompression should be done first.</span> <br><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<br><br />
'''Imaging studies:'''<BR><br />
<span style="color:red"> Don`t order imaging studies unless the patient is stabilized first.</span> <br><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]<BR><br />
<span style="font-size:85%;color:red">Don`t repeat needle aspiration unless there were technical difficulties</span> <br><br />
<span style="font-size:85%;color:red">Don`t remove the cannula, until the chest drain is inserted and is functioning properly</span> <br><br />
<br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Insert chest tube immediately after the needle decompression<br><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]])<br><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]] <br />
❑ Ensure [[asepsis]]<br><br />
❑ Administer adequate analgesics <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 />
❑ '''Site'''<br><br />
:❑Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR><br />
<br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Discharge and follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the opposite side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm <br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Rule out the following alternative diagnosis in uncertain cases:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Pericardial tamponade]] <br><br />
:❑ Muffled [[heart sounds]]<br />
:❑ [[Pulsus paradoxus]]<br />
❑ [[Pulmonary embolism]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | J01 | | | | |J01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> <span style="color:red"> ❑ '''Immediate''' intervention with needle decompression should be done first.</span> <br><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<br><br />
'''Imaging studies:'''<BR><br />
<span style="color:red"> Don`t order imaging studies unless the patient is stabilized first.</span> <br><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]<BR><br />
<span style="font-size:85%;color:red">Don`t repeat needle aspiration unless there were technical difficulties</span> <br><br />
<span style="font-size:85%;color:red">Don`t remove the cannula, until the chest drain is inserted and is functioning properly</span> <br><br />
<br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Insert chest tube immediately after the needle decompression<br><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]])<br><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]] <br />
❑ Ensure [[asepsis]]<br><br />
❑ Administer adequate analgesics <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 />
❑ '''Site'''<br><br />
:❑Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR><br />
<br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Discharge and follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the opposite side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm <br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Rule out the following alternative diagnosis in uncertain cases:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Pericardial tamponade]] <br><br />
:❑ Muffled [[heart sounds]]<br />
:❑ [[Pulsus paradoxus]]<br />
❑ [[Pulmonary embolism]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | J01 | | | | |J01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> <span style="color:red"> ❑ '''Immediate''' intervention with needle decompression should be done first.</span> <br><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<br><br />
'''Imaging studies:'''<BR><br />
<span style="color:red"> Don`t order imaging studies unless the patient is stabilized first.</span> <br><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]<BR><br />
<span style="font-size:85%;color:red">Don`t repeat needle aspiration unless there were technical difficulties</span> <br><br />
<span style="font-size:85%;color:red">Don`t remove the cannula, until the chest drain is inserted and is functioning properly</span> <br><br />
<br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Insert chest tube immediately after the needle decompression<br><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]])<br><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]] <br />
❑ Ensure [[asepsis]]<br><br />
❑ Administer adequate analgesics <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 />
❑ '''Site'''<br><br />
:❑Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR><br />
<br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Discharge and follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the opposite side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm <br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Rule out the following alternative diagnosis in uncertain cases:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Pericardial tamponade]] <br><br />
:❑ Muffled [[heart sounds]]<br />
:❑ [[Pulsus paradoxus]]<br />
❑ [[Pulmonary embolism]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | J01 | | | | |J01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> <span style="color:red"> ❑ '''Immediate''' intervention with needle decompression should be done first.</span> <br><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<br><br />
'''Imaging studies:'''<BR><br />
<span style="color:red"> Don`t order imaging studies unless the patient is stabilized first.</span> <br><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]<BR><br />
<span style="font-size:85%;color:red">Don`t repeat needle aspiration unless there were technical difficulties</span> <br><br />
<span style="font-size:85%;color:red">Don`t remove the cannula, until the chest drain is inserted and is functioning properly</span> <br><br />
<br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Insert chest tube immediately after the needle decompression<br><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]])<br><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]] <br />
❑ Ensure [[asepsis]]<br><br />
❑ Administer adequate analgesics <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 />
❑ '''Site'''<br><br />
:❑Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR><br />
<br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Discharge and follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the opposite side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm <br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Rule out the following alternative diagnosis in uncertain cases:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Pericardial tamponade]] <br><br />
:❑ Muffled [[heart sounds]]<br />
:❑ [[Pulsus paradoxus]]<br />
❑ [[Pulmonary embolism]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | J01 | | | | |J01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> <span style="color:red"> ❑ '''Immediate''' intervention with needle decompression should be done first.</span> <br><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<br><br />
'''Imaging studies:'''<BR><br />
<span style="color:red"> Don`t order imaging studies unless the patient is stabilized first.</span> <br><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]<BR><br />
<span style="font-size:85%;color:red">Don`t repeat needle aspiration unless there were technical difficulties</span> <br><br />
<span style="font-size:85%;color:red">Don`t remove the cannula, until the chest drain is inserted and is functioning properly</span> <br><br />
<br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Insert chest tube immediately after the needle decompression<br><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]])<br><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]] <br />
❑ Ensure [[asepsis]]<br><br />
❑ Administer adequate analgesics <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 />
❑ '''Site'''<br><br />
:❑Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR><br />
<br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Discharge and follow up'''<BR><br />
❑ All patients should be followed up by chest physician<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the opposite side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm <br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Rule out the following alternative diagnosis in uncertain cases:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Pericardial tamponade]] <br><br />
:❑ Muffled [[heart sounds]]<br />
:❑ [[Pulsus paradoxus]]<br />
❑ [[Pulmonary embolism]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | J01 | | | | |J01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> <span style="color:red"> ❑ '''Immediate''' intervention with needle decompression should be done first.</span> <br><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<br><br />
'''Imaging studies:'''<BR><br />
<span style="color:red"> Don`t order imaging studies unless the patient is stabilized first.</span> <br><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]<BR><br />
<span style="font-size:85%;color:red">Don`t repeat needle aspiration unless there were technical difficulties</span> <br><br />
<span style="font-size:85%;color:red">Don`t remove the cannula, until the chest drain is inserted and is functioning properly</span> <br><br />
<br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Insert chest tube immediately after the needle decompression<br><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]])<br><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]] <br />
❑ Ensure [[asepsis]]<br><br />
❑ Administer adequate analgesics <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 />
❑ '''Site'''<br><br />
:❑Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR><br />
<br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Discharge and follow up'''<BR><br />
❑ All patients should be followed up by chest physicians<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
</div></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><div style="width: 80%;"><br />
__NOTOC__<br />
{{CMG}}; {{AE}} {{MM}}; {{TS}}<br />
<br />
{{SK}} Collapsed lung; air around the lung; air outside the lung<br />
<br />
{| class="infobox" style="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;" cellpadding="0" cellspacing="0";<br />
|-<br />
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Tension Pneumothorax Resident Survival Guide Microchapters}}<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Overview|Overview]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Do's|Do's]]<br />
|-<br />
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> 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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention. It should be diagnosed based on the history and physical examination findings.</span> <br><br />
<br />
<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br><br />
{{familytree/start |summary=Diagnostic approach}}<br />
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br><br />
❑ [[Dyspnea]]<BR><br />
❑ [[Chest pain]]<BR><br />
❑ [[Cyanosis]]<BR><br />
❑ [[Sweating]]<BR><br />
❑ [[Anxiety]]<BR><br />
❑ [[Fatigue]]<BR><br />
❑ Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br><br />
❑ Recent invasive procedures<br><br />
:❑ [[Thoracentesis]]<br><br />
:❑ [[Central venous catheter]] insertion<br><br />
:❑ [[Bronchoscopy]]<br><br />
:❑ [[Biopsy|Pleural biopsy]]<br><br />
❑ [[Mechanical ventilation]]<br><br />
❑ [[Cardiopulmonary resuscitation]]<br><br />
❑ Presence of [[Drain (surgery)|chest drains]]<br><br />
❑ [[Hyperbaric oxygen]] treatment<br><br />
❑ [[Trauma|Chest wall trauma]] </div>}}<br />
<br />
{{familytree | | | | |!| | | | | }}<br />
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR><br />
'''Appearance of the patient'''<br><br />
❑ Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].<br />
<br />
'''Vital signs'''<BR><br />
<br />
❑ [[Pulse]]:<BR><br />
:❑ Rate<br />
::❑ [[Tachycardia]]<BR><br />
:❑ Rhythm<br><br />
::❑ Regular<br />
:❑ Strength<br />
::❑ Weak <br />
❑ [[Blood pressure]]<BR><br />
:❑ [[Hypotension]] <BR><br />
❑ [[Respiratory rate]]<BR><br />
:❑ [[Tachypnea]]<BR><br />
<br />
'''Skin'''<br><br />
<br />
❑ [[Cyanosis]]<br><br />
<br />
'''Neck'''<br><br />
<br />
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR><br />
<br />
'''Respiratory examination:'''<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><BR><br />
<br />
'''Inspection'''<BR><br />
❑ Enlarged involved [[hemithorax]]<BR><br />
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br><br />
'''Palpation'''<BR><br />
❑ Reduced [[lung expansion]] on the affected side <BR><br />
❑ [[Trachea]] shifted to the opposite side<BR><br />
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR><br />
❑ Displacement of the [[apex beat]]<BR><br />
'''Percussion'''<BR><br />
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR><br />
'''Auscultation'''<BR><br />
❑ Diminished [[breath sounds]] on the affected side<BR><br />
<br />
'''Additional findings in ventilated patients:'''<br><br />
<br />
❑ Decreased [[oxygen saturation]]<br><br />
❑ Increase in inflation pressure <br><br />
❑ Increase in [[peak airway pressure]]<br><br />
❑ Airway pressure alarm <br></div>}}<br />
<br />
{{familytree | | | | |!| | | | | | | | | }}<br />
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Rule out the following alternative diagnosis in uncertain cases:'''<br><br />
❑ [[Acute myocardial infarction]] <br><br />
:❑ Substernal chest discomfort or chest tightness<br />
❑ [[Pericardial tamponade]] <br><br />
:❑ Muffled [[heart sounds]]<br />
:❑ [[Pulsus paradoxus]]<br />
❑ [[Pulmonary embolism]]<br><br />
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br><br />
:❑ Physical exam is suggestive of [[DVT]]</div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | J01 | | | | |J01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> <span style="color:red"> ❑ '''Immediate''' intervention with needle decompression should be done first.</span> <br><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<br><br />
'''Imaging studies:'''<BR><br />
<span style="color:red"> Don`t order imaging studies unless the patient is stabilized first.</span> <br><br />
❑ Perform [[chest X-ray]]<BR><br />
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
[[File:Pneumothorax CXR.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><br />
Left-sided [[tension pneumothorax]]<BR><br />
:❑ Air in the [[pleural cavity]]<BR><br />
:❑ Contralateral deviation of [[mediastinum]]<BR><br />
:❑ Increased thoracic volume<BR><br />
:❑ Ipsilateral flattening of heart border<BR><br />
:❑ Mid diaphragmatic depression<BR><br />
❑ Chest CT scanning<BR><br />
:❑ For uncertain or complex cases<br />
[[File:Pneumothorax CT.jpg|250px]]<BR><br />
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br><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).<BR><br />
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br><br />
❑ Perform emergent needle decompression (14-16 G)<br><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}<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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br><br />
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}<br />
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR><br />
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR><br />
❑ Immediately cover [[penetrating chest wounds]] with an occlusive or pressure bandage in trauma patients<BR><br />
❑ Administer 100% oxygen <ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR><br />
❑ Seek expert consultation (thoracic surgeon)<br></div>}}<br />
{{familytree | | | | |!| | | | | |}}<br />
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<br />
❑ Aseptic preparation<BR><br />
:❑ Use alcohol-based skin disinfectants (two applications)<BR><br />
❑ Use 14-16 G intravenous cannula<BR><br />
❑ Site<br />
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR><br />
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br />
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]<BR><br />
<span style="font-size:85%;color:red">Don`t repeat needle aspiration unless there were technical difficulties</span> <br><br />
<span style="font-size:85%;color:red">Don`t remove the cannula, until the chest drain is inserted and is functioning properly</span> <br><br />
[[File:Site of needle insertion - 11.jpg|350px]]<BR><br />
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}<br />
<SMALL>''Video adapted from Youtube.com''</SMALL><br />
</div>}}<br />
{{familytree | | | | |!| | | | | | | }}<br />
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR><br />
❑ Obtain the [[informed consent]]<BR><br />
❑ Insert chest tube immediately after the needle decompression<br><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]])<br><br />
❑ Use imaging guidance<BR><br />
:❑ A recent [[chest X-ray]] <br />
❑ Ensure [[asepsis]]<br><br />
❑ Administer adequate analgesics <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 />
❑ '''Site'''<br><br />
:❑Insert chest tube at the triangle of safety bordered by:<BR><br />
::❑ Superiorly: the base of the [[axilla]]<BR><br />
::❑ Anteriorly: lateral edge of [[pectoralis major]]<BR><br />
::❑ Laterally: lateral edge of [[latissimus dorsi]]<BR><br />
::❑ Inferiorly: the line of the [[fifth intercostal space]]<BR><br />
<br />
[[File:Triangle of safety-11.jpg|400px]]<BR><br />
<br />
❑ [[Chest tube|Insert the chest tube]]<br><br />
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR><br />
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR></div>}}<br />
{{familytree | | | | |!| | | | | | }}<br />
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Discharge and follow up'''<BR><br />
❑ All patients should be followed up by chest physicians<BR><br />
❑ Advise to return to hospital if increasing breathlessness develops<BR><br />
❑ Advise to avoid air travel<BR><br />
❑ Advise to avoid diving <BR><br />
</div>}}<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.<ref name="pmid19561940">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><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.<ref name="pmid20696690">{{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&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }}</ref><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 />
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Mohamed Moubarak