Medical Care Treatment, prevention, and termination of pacemaker-mediated tachycardia (PMT) typically involves altering the pacemaker programming to prevent sensing of the retrograde P wave. This is most easily done by prolonging the postventricular atrial refractory period (PVARP).
Full Answer
What is the treatment of choice for otitis media?
Topical antibiotic is the treatment of choice in acute tube otorrhea. Symptomatic hearing loss due to persistent otitis media with effusion is best treated with tympanostomy tubes. Novel molecular and biomaterial treatments as adjuvants to surgical closure of eardrum perforations seem promising.
What is the pathophysiology of acute otitis media?
Acute otitis media is usually a complication of eustachian tube dysfunction that occurs during a viral upper respiratory tract infection. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms isolated from middle ear fluid. Management of acute otitis media should begin with adequate analgesia.
When is aspiration of the middle ear indicated for otitis media?
Myringotomy and aspiration of the middle ear effusion is indicated for acute otitis media: (1) when a child has persistent or recurrent symptoms while on appropriate antimicrobial therapy; (2) if there is seve … In summary there are four surgical procedures commonly used for treatment of otitis media.
What happens when the otitis media does not drain properly?
When this tube is not working properly, it prevents normal drainage of fluid from the middle ear, causing a build up of fluid behind the eardrum. When this fluid cannot drain, it allows for the growth of bacteria and viruses in the ear that can lead to acute otitis media.
Do you need antibiotic prophylaxis for mechanical heart valve?
PATIENTS UNDERGOING CARDIAC SURGERY Patients who undergo surgery for prosthetic heart valves or intravascular or intracardiac materials are at risk of infection. Because morbidity and mortality associated with these infections are high, perioperative antibiotic prophylaxis is recommended.
What drug is contraindicated with a mechanical heart valve?
Pradaxa is not approved for patients with atrial fibrillation caused by heart valve problems. FDA is requiring a contraindication (a warning against use) of Pradaxa in patients with mechanical heart valves.
What is the appropriate regimen of antibiotic for a patient with a heart valve prosthesis?
Patients with prosthetic valve infection with MSSA should be treated with a combination of oxacillin or nafcillin and rifampin (300 mg orally every eight hours) for at least six weeks. In addition, gentamicin should be administered during the first two weeks of this course of therapy.
Which drug is recommended for anticoagulation in a patient with a prosthetic heart valve?
All patients with mechanical prosthetic valves require lifelong anticoagulation with a VKA (eg, warfarin). DOACs include the oral direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban, apixaban, and edoxaban.
What blood thinners can you take with a mechanical heart valve?
Vitamin K antagonists are the only anticoagulants licensed for use in patients with mechanical heart valves. Among these, warfarin is most commonly prescribed.
Can you take Plavix if you have an artificial heart valve?
Plavix (clopidogrel) is also sometimes used to prevent blood clots in people with mitral valve disease (a condition that affects the valve that separates the left upper and lower chambers of the heart) prosthetic (artificial) heart valves, and people undergoing certain heart procedures such as coronary artery stent ...
In which of the following should antibiotic prophylaxis not be considered?
Prophylaxis is not advised for routine gastrointestinal or genitourinary procedures.
What antibiotic is used for heart infection?
A combination of penicillin or ampicillin with gentamicin is appropriate for endocarditis caused by enterococci that are not highly resistant to penicillin. Vancomycin should be substituted for penicillin when high-level resistance is present.
Can Rocephin and vancomycin be given together?
Interactions between your drugs No interactions were found between Rocephin and vancomycin.
Why do patients with mechanical heart valves require anticoagulation?
Although mechanical heart valves (MHV) are more durable than tissue valves, they are more thrombogenic. Consequently, patients with MHV require long-term anticoagulation with vitamin K antagonists, such as warfarin.
Is Lovenox approved for mechanical valves?
“Prosthetic Heart Valves: The use of Lovenox Injection is not recommended for thromboprophylaxis in patients with prosthetic heart valves. Cases of prosthetic heart valve thrombosis have been reported in patients with prosthetic valves who have received enoxaparin for thromboprophylaxis.
Can you take apixaban with a mechanical heart valve?
Conclusions: Apixaban is a promising candidate and may be a useful alternative to warfarin for thromboprophylaxis of mechanical heart valves. Unlike warfarin, no adverse bleeding events were observed in any apixaban groups.
What are the different types of otitis media?
Different types of otitis media include the following: Acute otitis media. This middle ear infection occurs abruptly causing swelling and redness. Fluid and mucus become trapped inside the ear, causing the child to have a fever and ear pain. Otitis media with effusion. Fluid (effusion) and mucus continue to accumulate in ...
How is otitis media diagnosed?
In addition to a complete medical history and physical examination, your child's health care provider will inspect the outer ear (s) and eardrum (s) using an otoscope. The otoscope is a lighted instrument that allows the health care provider to see inside the ear. A pneumatic otoscope blows a puff of air into the ear to test eardrum movement.
What causes ear infections?
Middle ear infections are usually a result of a malfunction of the eustachian tube, a canal that links the middle ear with the throat area . The eustachian tube helps to equalize the pressure between the outer ear and the middle ear. When this tube is not working properly, it prevents normal drainage of fluid from the middle ear, causing a build up of fluid behind the eardrum. When this fluid cannot drain, it allows for the growth of bacteria and viruses in the ear that can lead to acute otitis media. The following are some of the reasons that the eustachian tube may not work properly:
How do you know if you have otitis media?
Ear Infection Symptoms. The following are the most common symptoms of otitis media. However, each child may experience symptoms differently. Symptoms may include: Unusual irritability. Difficulty sleeping or staying asleep. Tugging or pulling at one or both ears. Fever, especially in infants and younger children.
Why is my eustachian tube not working?
The following are some of the reasons that the eustachian tube may not work properly: A cold or allergy which can lead to swelling and congestion of the lining of the nose, throat, and eustachian tube (this swelling prevents the normal drainage of fluids from the ear) A malformation of the eustachian tube.
What is the name of the inflammation in the middle of the ear?
Middle Ear Infection. Otitis media is inflammation or infection located in the middle ear. Otitis media can occur as a result of a cold, sore throat, or respiratory infection.
Why is tympanometry important?
Tympanometry is a test that can be performed in most health care providers' offices to help determine how the middle ear is functioning. It does not tell if the child is hearing or not, but helps to detect any changes in pressure in the middle ear. This is a difficult test to perform in younger children because the child needs to remain still and not cry, talk, or move.
Why does otitis media hurt?
Chronic suppurative otitis media may become exacerbated after an upper respiratory infection or when water enters the middle ear through a tympanic membrane (TM) perforation during bathing or swimming. Infections often are caused by gram-negative bacilli or Staphylococcus aureus, resulting in painless, purulent, sometimes foul-smelling otorrhea.
What is the diagnosis of suppurative otitis media?
Diagnosis of chronic suppurative otitis media is usually clinical. Drainage is cultured. When cholesteatoma or other complications are suspected (as in a febrile patient or one with vertigo or otalgia), CT or MRI is done. These tests may reveal intratemporal or intracranial processes (eg, labyrinthitis, ossicular or temporal erosion, abscesses). If patients have persistent or recurrent granulation tissue, biopsies should be done to exclude recurrent neoplasm.
How long does it take for otitis media to drain?
Chronic suppurative otitis media is a persistent, chronically draining ( > 6 weeks), suppurative perforation of the tympanic membrane. Symptoms include painless otorrhea with conductive hearing loss. Complications include development of aural polyps, cholesteatoma, and other infections. Treatment requires complete cleaning of the ear canal several times daily, careful removal of granulation tissue, and application of topical corticosteroids and antibiotics. Systemic antibiotics and surgery are reserved for severe cases.
What is the epithelial growth in the middle ear?
A cholesteatoma is an epithelial cell growth that forms in the middle ear, mastoid, or epitympanum after chronic suppurative otitis media. Lytic enzymes, such as collagenases, produced by the cholesteatoma can destroy adjacent bone and soft tissue.
What is tympanoplasty for?
Tympanoplasty is indicated for patients with marginal or attic perforations and chronic central tympanic membrane perforations. A disrupted ossicular chain may be repaired during tympanoplasty as well.
What is the white debris in the middle of the ear?
A patient with cholesteatoma has white debris in the middle ear, a draining polypoid mass protruding through the tympanic membrane perforation, and an ear canal that appears clogged with mucopurulent granulation tissue. Cholesteatoma. PROFESSOR TONY WRIGHT, INSTITUTE OF LARYNGOLOGY & OTOLOGY/SCIENCE PHOTO LIBRARY.
Does otitis media cause hearing loss?
Chronic suppurative otitis media usually manifests with conductive hearing loss and otorrhea. Pain is uncommon unless an associated osteitis of the temporal bone occurs. The tympanic membrane is perforated and draining, and the auditory canal is macerated and littered with granulation tissue.
What is TAVR surgery?
Transcatheter aortic valve replacement, or TAVR, is a relatively new, minimally invasive surgical procedure that repairs the aortic heart valve without needing to remove the old valve. Often a patient spends less time recovering and avoids some of the risks associated with open-heart valve replacement. It is typically recommended for patients who are not able to undergo a traditional open-heart procedure—many times, these are people in their 80s or 90s who have other medical conditions that make an open-heart surgery a less preferred option.
Can you have open heart surgery in your 80s?
It is typically recommended for patients who are not able to undergo a traditional open-heart procedure—many times, these are people in their 80s or 90s who have other medical conditions that make an open-heart surgery a less preferred option.
Can a pacemaker be used after a TAVR?
However, when a pacemaker is needed soon after TAVR, patients often have worse outcomes than those who did not need a pacemaker, according to a study published today in JACC: Cardiovascular Interventions. The study shows that the risks are both short- and long-term and include lengthier hospital and intensive care unit stays as well as a greater risk of death.
What is otitis media?
Otitis describes inflammation of the ear caused by infectious or noninfectious processes. Acute otitis externa (AOE) is cellulitis of the ear canal skin, which is almost entirely caused by bacteria [ 1 ]. Otitis media (OM) concerns the middle ear and is further delineated as otitis media with effusion (OME) or acute otitis media (AOM). Although middle ear effusion is present in both AOM and OME, AOM is differentiated from OME by signs and symptoms of acute infection. In practice differentiating AOM from OME can be subjective, which can result in overtreatment of OME with antibiotics [ 2 ]. Collectively, OM is common in children and is the most common reason children receive antibiotics.
What are the risk factors for otitis?
Many patients had established risk factors for otitis infections, as identified in studies of pediatric patients, such as co-diagnosis with an additional ARI, a history of OM, allergic rhinitis, and exposure to tobacco smoke. Also, patients with an ARI co-diagnosis were more likely to receive systemic antibiotics (448/619 [72%]) compared with those without an ARI co-diagnosis (1609/3143 [51%]; P < .001). Although 12% of the cohort were current smokers, this is similar to the veteran population as a whole [ 24 ].
How many visits were there in the OME study?
There were 912, 1778, and 1306 patient-visits included in the incidence calculations for OME, AOM, and AOE, respectively, and 668 513 patient-years during the period of observation. The incidence rates were 4.0 (95% CI, 3.9–4.2) per 1000 patient-years for any diagnoses of OM. By comparison, the incidence rates for acute pharyngitis and sinusitis were 8.4 (95% CI, 8.2–8.6) and 15.2 (95% CI, 14.9–15.5) per 1000 patient-years, respectively ( Figure 2 ).
How many patients with AOE are prescribed antibiotics?
Systemic antibiotics were prescribed in a substantial number of patients with AOE (21%) . Practice guidelines recommend considering systemic antibiotics for AOE in patients with immunocompromised states or diabetes, but only 5/257 (2%) and 63/257 (25%) AOE patients with systemic antibiotics prescribed had comorbid immunosuppression or diabetes, respectively [ 17 ].
Is otitis more common in adult patients?
We observed a significant number of adult patients with a cute otitis diagnoses and found that OM in particular is diagnosed more commonly in adult patients than previously thought. Antibiotic prescribing was often discordant with guideline recommendations for AOE and pediatric guidelines for OME and AOM. Most clinical outcomes were similar irrespective of treatment strategy, which suggests that OM and AOE may be a fruitful diagnosis for future outpatient antibiotic stewardship initiatives among adult patients.
Can you use amoxicillin for AOM?
Pediatric AOM guidelines recommend that amoxicillin should be used as the firstline treatment , with amoxicillin/clavulanate being reserved for specific circumstances : concurrent conjunctivitis, treatment with amoxicillin in the past 30 days, or history of recurrent AOM unresponsive to amoxicillin [ 2, 14 ]. Visits with conjunctivitis co-diagnoses or history of recurrent AOM were excluded, and of the AOM visits where amoxicillin/clavulanate was prescribed, only 24/448 (5%) patients received amoxicillin or amoxicillin/clavulanate in the past 30 days. The rate of use of amoxicillin for AOM in our study (35%) was much lower than in a national study examining pediatric AOM prescribing, in which 54% of antibiotics for AOM in children were amoxicillin [ 26 ]. We previously have observed high rates of amoxicillin/clavulanate use in the treatment of pharyngitis within the VA where it is clearly not indicated [ 18, 25 ]. None of the facilities included in this analysis have clinical order sets within the electronic health record specific to management of otitis. However, increasing the use of amoxicillin when antibiotics are needed is another stewardship opportunity for adults with AOM.
Is otitis media a common pharyngitis?
Administrative data indicated that otitis media diagnoses in adults were half as common as acute pharyngitis, and the majority received antibiotic treatment, which may be inappropriate. Prospective studies verifying diagnostic accuracy and antibiotic appropriateness are warranted.
How to treat pacemaker-mediated tachycardia?
Treatment, prevention, and termination of pacemaker-mediated tachycardia (PMT) typically involves altering the pacemaker programming to prevent sensing of the retrograde P wave. This is most easily done by prolonging the PVARP. During the PVARP, the atrial lead does not sense any atrial activity; hence, ventricular pacing is not triggered. Note that prolonging PVARP may affect the upper tracking rate of the pacemaker, which is defined by the total atrial refractory period (TARP), ie, TARP = AV delay + PVARP. For example, if the AV delay is 180 milliseconds (ms) and the PVARP is increased from 320 to 420 ms, the TARP then changes from 500 ms (120 bpm) to 600 ms, which corresponds to an upper rate of 100 bpm (rate = 60,000/cycle length [ms]). This means that the pacemaker will not track atrial rates above 100 bpm and could lead to 2:1 block at rates ≥100 bpm in patients with heart block. In some pacemakers, the upper tracking rate can be programmed independently from the upper rate based on rate response.
What is AV tracing?
Telemetered ECG tracing showing atrioventricular (AV)–paced rhythm at 60/min after termination of the pacemaker-mediated tachycardia (PMT). The tracing, from top to bottom, shows lead II, atrial electrogram, ventricular electrogram, and marker channels. The intracardiac markers indicate the rhythm is atrial paced (AP) and ventricular paced (VP). Note that the VP beats are ventricular pseudofusion beats.
How does a magnet work in PMT?
In acute situations, when a patient is very symptomatic, regardless of the pacemaker model or when a programmer is unavailable, applying a magnet over the pacemaker inhibits sensing and makes the pacemaker pace asynchronously in the atrium and ventricle, thus terminating the PMT by blocking the antegrade limb of the circuit (by prevention of atrial tracking). Carotid sinus massage or AV nodal blocking drugs such as adenosine, verapamil, or beta-blockers can block VA conduction (ie, retrograde conduction) directly and can terminate PMT.
Can a pacemaker stop tachycardia?
Alternatively, prevention of one ventricular paced beat can also stop the tachycardia. Some pacemakers use this algorithm. of 3.
Does PVARP affect ventricular pacing?
During the PVARP, the atrial lead does not sense any atrial activity; hence, ventricular pacing is not triggered. Note that prolonging PVARP may affect the upper tracking rate of the pacemaker, which is defined by the total atrial refractory period (TARP), ie, TARP = AV delay + PVARP.
Can dual chamber pacemakers detect PMT?
Most modern dual-chamber pacemakers are capable of detecting PMT and initiating PMT intervention by automatically prolonging the PVARP for the beat after a ventricular-sensed event that is not preceded by atrial pacing, ie, a PVC (PVARP extension). This problem also can be minimized by the use of adaptive PVARP in rate-responsive (DDDR) pacemakers; the PVARP is long when the patient is at rest and shortens when the sensor indicates activity, allowing the pacemaker to track higher atrial rates with minimal risk of PMT.