Rosen & Barkin's 5-Minute Emergency Medicine Consult (526 page)

• Inflammation, infection, or infiltration of the pericardial sac surrounding the heart:
  
  • Pericardial effusion may or may not be present.
    
• Acute pericarditis:
  
  • Rapid in onset
    
  • Potentially complicated by cardiac tamponade from effusion
    
• Constrictive pericarditis:
  
  • Results from chronic inflammation causing thickening and adherence of the pericardium to the heart
    

• Idiopathic (most common)
  
• Viral:
  
  • Echovirus
    
  • Coxsackie
    
  • Adenovirus
    
  • Varicella
    
  • Epstein–Barr virus
    
  • Cytomegalovirus
    
  • Hepatitis B
    
  • Mumps
    
  • HIV
    
• Bacterial:
  
  • Tuberculosis
    
  • Staphylococcus
    
  • Streptococcus
    
  • Haemophilus
    
  • Salmonella
    
  • Legionella
    
• Fungal:
  
  • Candida
    
  • Aspergillus
    
  • Histoplasmosis
    
  • Coccidioidomycosis
    
  • Blastomycosis
    
  • Nocardia
    
• Parasitic:
  
  • Amebiasis
    
  • Toxoplasmosis
    
  • Echinococcosis
    
• Neoplastic:
  
  • Lung
    
  • Breast
    
  • Lymphoma
    
• Uremia
  
• Myocardial infarction:
  
  • Dressler syndrome
    
• Connective tissue disease:
  
  • Systemic lupus erythematosus
    
  • Rheumatoid arthritis
    
  • Scleroderma
    
• Radiation
  
• Chest trauma
  
• Postpericardiotomy
  
• Aortic dissection
  
• Myxedema
  
• Pancreatitis
  
• Inflammatory bowel disease
  
• Amyloidosis
  
• Drugs:
  
  • Procainamide
    
  • Cromolyn sodium
    
  • Hydralazine
    
  • Dantrolene
    
  • Isoniazid
    
  • Penicillins
    
  • Doxorubicin/daunorubicin
    

DIAGNOSIS

• Chest pain
  
• Fever
  
• Mild dyspnea
  
• Cough
  
• Hoarseness
  
• Nausea
  
• Anorexia
  

• Chest pain:
  
  • Pain radiating to the ridge of the trapezius from phrenic irritation
    
  • Central or substernal pain
    
  • Sudden onset
    
  • Sharp
    
  • Pleuritic
    
  • Worse when supine or with cough
    
  • Improved with leaning or sitting forward
    
• Previous episodes of pericarditis
  
• History of fever or infection
  
• History of malignancy or autoimmune disease
  

• Tachypnea
  
• Tachycardia
  
• Odynophagia
  
• Friction rub:
  
  • Heard best at lower left sternal border
    
  • Very specific
    
  • Triphasic rub is classic
    
  • Can have any of these 3 components:
    
    • Presystolic
      
    • Systolic
      
    • Early diastolic
      
  • Intermittent and exacerbated by leaning forward
    
• Beck triad with the accumulation of pericardial fluid:
  
  • Muffled heart sounds
    
  • Increased venous pressure (distended neck veins)
    
  • Decreased systemic arterial pressure (hypotension)
    
• Ewart sign:
  
  • Dullness and bronchial breathing between the tip of the left scapula and the vertebral column
    
• Pulsus paradoxus:
  
  • Exaggerated decrease (>10 mm Hg) in systolic pressure with inspiration
    
• Constrictive pericarditis:
  
  • Signs of both right- and left-sided heart failure
    
  • Pulmonary and peripheral edema
    
  • Ascites
    
  • Hepatic congestion
    

• ECG has 4 classic stages
  
• Stage 1:
  
  • Concave ST-elevations diffusely except aVR and V1
    
  • PR segment depressions with elevation in aVR
    
• Stage 2:
  
  • Normalization of ST and PR segments
    
  • T-wave flattening
    
• Stage 3:
  
  • Diffuse T-wave inversions
    
• Stage 4:
  
  • T-waves normalize, may have some persistent T-wave inversions
    
• Atypical changes may include localized ST-elevations or T-wave inversions
  
• Myocardial involvement suggested by intraventricular conduction delay, new bundle branch block, or Q-waves
  
• Pericardial effusion suggested by electrical alternans
  

• CBC:
  
  • May show leukocytosis
    
• Erythrocyte sedimentation rate and C-reactive protein:
  
  • May be elevated, can follow for resolution
    
• Cardiac enzymes:
  
  • Helpful in distinguishing pericarditis from myocardial infarction
    
  • May also be elevated in myopericarditis
    

• CXR:
  
  • Most often normal
    
  • May show enlargement of the cardiac silhouette or calcification of pericardium
    
  • No change in heart size until >250 mL of fluid has accumulated in the pericardial sac
    
• Echocardiography:
  
  • Diagnostic method of choice for the detection of pericardial fluid
    
  • Can detect as little as 15 mL of fluid in the pericardial sac
    
  • Bedside US good screening tool
    
• Chest CT:
  
  • Useful for the detection of calcifications or thickening of the pericardium
    
  • Can help rule out other etiologies
    

Pericardiocentesis:

• Pericardial fluid can help determine underlying etiology.
  
• Fluid sent for protein, glucose, culture, cytology, Gram and acid-fast stains, and fungal smears
  

• Acute myocardial infarction
  
• Pulmonary embolism
  
• Pneumothorax
  
• Aortic dissection
  
• Pneumonia
  
• Empyema
  
• Cholecystitis
  
• Pancreatitis
  

TREATMENT

• ABCs, IV access, O
  ₂
  , monitor
  
• Consider fluid bolus if no crackles.
  

• ABCs
  
• Emergent pericardiocentesis:
  
  • For hemodynamic compromise secondary to cardiac tamponade
    
  • Removal of a small amount of fluid can lead to a dramatic improvement.
    
  • US guidance if available
    

• Treatment dependent on the underlying etiology
  
• Idiopathic, viral, rheumatologic, and post-traumatic:
  
  • NSAID regimens effective
    
  • Corticosteroids reserved for refractory cases
    
• Bacterial:
  
  • Aggressive treatment with IV antibiotics along with drainage of the pericardial space
    
  • Search for primary focus of infection.
    
  • Therapy guided by determination of pathogen from pericardial fluid tests
    
• Neoplastic:
  
  • Treat underlying malignancy.
    
• Uremic:
  
  • Intensive 2–6 wk course of dialysis
    
  • Caution should be used if using nonsteroidal medications.
    
• Expected course/prognosis:
  
  • Most patients will respond to treatment within 2 wk.
    
  • Most have complete resolution of symptoms.
    
• Few progress to recurrent episodes with eventual development of constrictive pericarditis or cardiac tamponade.
  

• Ibuprofen 300–800 mg q6–8h for days to weeks depending on severity:
  
  • Can also be tapered to prevent recurrence
    
  • Improves coronary blood flow
    
  • GI prophylaxis with 20 mg omeprazole
    
• Aspirin 800 mg PO q6–8h × 7–10 days:
  
  • Taper off over 3–4 wk
    
  • Omeprazole as with ibuprofen
    
  • Colchicine 1–2 mg × 1 day, then 0.5–1 mg daily × 3 mo
    
• Colchicine alone: 1–2 mg × 1 day, then 0.5–1 mg daily × 3 mo:
  
  • Combination with aspirin decreased recurrence rate
    
  • Lower doses may also be effective.
    
• Indomethacin 25–50 mg q6h:
  
  • May restrict coronary blood flow
    
• Prednisone 0.2–0.5 mg/kg daily × 2–4 wk with taper:
  
  • Used for refractory cases
    
  • For use if aspirin/NSAIDs contraindicated
    
  • Associated with increased rate of recurrence
    
  • Also beneficial in uremic and autoimmune pericarditis
    

• NSAIDs and aspirin are not teratogenic in 1st 20 wk of pregnancy
  
• Glucocorticoids may be used during pregnancy.
  
• Avoid aspirin and high-dose steroids when breast-feeding.
  
• Colchicine is generally contraindicated except with familial Mediterranean fever.
  

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