SIMULATION CASEBOOK - MyCourses

Gilbert Program in Medical Simulation
Simulation Casebook
Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12
f. Treatment
i. Effect of nitroglycerin: increased chest pain when preload and
afterload drops in setting of aortic stenosis
ii. Role of IV fluids: increase back flow to coronary arteries
iii. More definitive management: will need echocardiography for the
diagnosis and assessment of AS severity.
iv. Stress imaging will also be important given the need to ROMI,
however, if significant AS is found on echo, together with symptoms
of angina, coronary angiography should be considered, given that
noninvasive tests for cardiac ischemia are less accurate in AS
patients
3. Didactic material: Part II
a. Pathophysiology
i. LVH as a response to increased afterload
1. Resulting S4
2. Hypotension due to loss of atrial kick in atrial fibrillation
and impaired filling of stiff ventricle
ii. Rales: interstitium "popping open" against water surface tension
iii. Atrial fibrillation and implications of rapid ventricular response
iv. Troponin elevation due to leak secondary to strain from rapid
ventricular response
b. Treatment
i. Effect of B-blocker on contractility and pressure
ii. Urgent cardioversion to control rate given hemodynamic instability
iii. Rate control if patient is hemodynamically stable
iv. More thorough discussion on chemical/electrical cardioversion and
aftercare
v. Comment on classic symptoms of AS (syncope, angina, heart
failure/DOE) and dramatic increase in mortality once patients
become symptomatic
IX.
Development and Deployment
This two step/paired case was developed as an exercise within the medical school’s physiology class, and
is a required experience for the entire first-year class. It has been used for several years.
X. Authors/Contributors
Case drafted by James Gordon, M.D., with contributions and updates by the Gilbert Simulation Team.
Compiled and formatted by Elan Guterman.
Reviewed and edited with references by Jeffrey Siegelman, M.D. and Zoë Howard, M.D.
XI.
References
Bonow, RO, Carabello, BA, Chatterjee, K, et al. ACC/AHA 2006 guidelines for the management of
patients with valvular heart disease. A report of the American College of Cardiology/American Heart
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