4.4 PERICARDITIS

Question 1

Anatomy

Answer 1

(1) Pericardium surrounds, protects and holds the heart in place
(2) Two parts of the pericardium:
(a) Fibrous pericardium: tough, inelastic and outer connective tissue
(b) Serous pericardium: thinner, delicate and forms double layer around the heart
1) Parietal layer
2) Visceral layer (on the heart itself touching the epicardium of the heart)
(3) Pericardium functions to protect the heart by:
(a) Anchoring the heart in place
(b) Prevents it from over stretching
(c) Has lubricating fluid (pericardial fluid) – prevents friction between membranes

Question 2

Pathophysiology:

Answer 2

(1) Pericarditis means inflammation of the pericardium
(2) It is mostly caused by viral infections in males < 50 years old
(a) Most common organisms is Coxsackieviruses and Echovirus
(b) Other viruses include Influenza, Epstein-Barr, Hepatitis, Mumps, CMV, and HIV
(c) Bacterial etiologies: Small pox vaccine, Neisseria gonorrhea, Chlamydia, Mycoplasma, and Lyme
(3) Other Causes include
(a) Radiation therapy
(b) Neoplasm
(c) Post-cardiac surgery
(d) Blunt or penetrating trauma
(e) Uremia
(f) Hypothyroidism
(g) AMI
(h) SLE, Rheumatoid arthritis, vasculitis
(i) Inflammatory bowel disease
(j) Drug induced (Penicillin, Minoxidil, procainamide)

Question 3

Symptoms and Physical Findings

Answer 3

(1) Substernal chest pain which is usually pleuritic (sharp), possible radiation to neck, shoulder, or arm
(2) Pain is worse when supine and relieved by sitting up and leaning forward
(3) Fever
(4) Pericardial friction rub is most common sign (sounds like Velcro/crunching snow)

Question 4

Differential Diagnosis

Answer 4

(1) AMI
(2) PE
(3) Pericardial effusion
(4) Myocarditis
(5) Aortic dissection
(6) Pleurisy (with pleural friction rub)
(7) Pneumonia

Question 5

Labs/Studies/EKG

Answer 5

(1) CBC may have elevated WBC due to infection and inflammation
(2) Cardiac enzymes will be elevated if due to myocarditis
(3) CXR to evaluate for pneumonia or widened mediastinum
(4) EKG: diffuse ST-segment elevation

Question 6

Treatment

Answer 6

(1) Viral pericarditis
(a) Aspirin 325-650 mg every 6 hours or
(b) NSAIDS (Indomethacin, Motrin or Naproxen) for up to 3 weeks

Question 7

Initial Care

Answer 7

(1) Aspirin or NSAID administration
(2) Close follow up to monitor for any signs of complications
(3) May keep on board if patient is stable
(4) Transfer patient if they do not show signs of improvement or symptoms
worsen

Question 8

Complications

Answer 8

(1) Pericardial effusion

(2) Pericardial Tamponade