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Heart sounds
Splitting of S2
INSPIRATION
EXPIRATION
Normal
splitting
s1
A2
P2
s1
A2
P2
Wide splitting
(PS,MR,RBB
B, VSD,PDA
s1
A2
P2
s1
A2
P2
Paradoxical
splitting (AS,
LBBB, HCM,
LVH)
s1
P2
A2 s1
P2
A2
Fixed splitting
(ASD)
s1
A2
P2
s1
A2
P2
Etiology:
Myxomatous degeneration
Rheumatic disease
Endocarditis
Grades 1 to 4
Surgical indications
If symptomatic
EF<60%
LVES diameter >4.5cm
Pulmonary pressure >55mmg Hg
Aortic Stenosis
Aortic Stenosis
Location of
murmur
Second
sound
Carotid
Pulse
HCM
LSB,
With thrill
Not radiating
Slowly rising
Brisk or bifid
Present A2
Initial
Rise
Peak
Return to
normal
Benefits
Troponin
2-4 hr
10 -24 hr
5 -10 days
CK-MB
3-4 hr
10-24 hr
2 4 days
LDH
10 hr
24 -72 hr
14 days
Myoglobin
1-2 hr
4 -8 hr
24 hours
Aspirin
Nitroglycerin
Oxygen
Analgesia
Treatment
Beta-Blockers
Anticoagulation
Anti-Platelet Agents
Thrombolysis
Percutaneous Coronary
Interventions (PCI)
Causes of Syncope
Syncope: Pathophysiology
Decreased cerebral
perfusion is common to all
causes of syncope
Cessation of cerebral
perfusion for as little as 35 seconds can result in
syncope
Decreased cerebral
perfusion may occur as a
result of decreased cardiac
output or decreased
systemic vascular
resistance.
More Pathophysiology
Bilateral hemisphere
dysfunction or
reticular activating
system (RAS)
midbrain knockout.
Generally acute
hypoperfusion is
responsible.
Regional
(vasoconstriction)
Systemic (global
hypotension)
Loss of consciousness
causes loss of postural
tone leading to collapse
35% reduction in
cerebral blood flow will
cause syncope.
Modifying factors
Cardiac output
Systemic and local vascular
resistance/occlusion
Blood volume
Ability to compensate
Syncope: Etiology
Mnemonic: PASSOUT
P-ressue (hypotensive causes)
A-rrthymias
S-eizures
S-ugar (hypo/hyper glycemia)
O-utput (cardiac)/ O2 (hypoxia)
U-nusual causes
T-ransient (TIAs, strokes, CNS diseases)
Syncope
CAUSES (Head---Heart---Vessels)
Reflex mediated
Cardiac
Mechanical , arrhythmias
Orthostatic
Cerebrovascular
Unknown
Nonsyncopal causes
sinus bradycardia
ventricular tachycardia
3 or more beats
WPW
Prolonged QT interval
Other: sinus pause> 2 sec, SVT, afib, 2nd or 3rd AV block, PM malfunction