Ex2 Pericardial Dx

Question 1

Hallmark sign: Pericarditis

Answer 1

chest pain - worsens with deep breath, relieved when sitting forward

Question 2

Auscultation of pericarditis

Answer 2

friction rub

Question 3

pericarditis ECG changes

Answer 3

occurs 90% of time
Stage I: ST segment elevation, PR segment depr.
Stage III: T wave inversion

Question 4

Causes of Pericarditis

Answer 4

Infective
1-2d post MI
Dresslers syndrome (autoimmune)
Penetrating trauma, PPM, metastatic dx, systemic dx

Question 5

Dresslers syndrome

Answer 5

post MI - necrotic myocardium tissue enters circulation + acts like antigen

Question 6

Pericarditis Tx

Answer 6

Salicyclates, other NSAIDs
ASA or Ketorolac
Symptomatic relief: codeine (esp helpful if + cough)
Steroids: reserved for refractory cases (assoc. pericardial relapse)

Question 7

accumulation of fluid surrounding heart

Answer 7

pericardial effusion

fluid in pericardial sac

Question 8

Normal volume in pericardial sac vs. pericardial effusion

Answer 8

norm=5-50
effusion > 100mL
(up to 2L if chronic)

Question 9

pressure of pericardial fluid impairs cardiac filling

Answer 9

cardiac tamponade

Question 10

types of pericardial effusion

Answer 10

atraumatic (serosanguinous/exudative) - neoplasm

traumatic (blood)

Question 11

S/S cardiac tamponade

Answer 11

Ventricular discordance
Becks triad
Increased CVP

Question 12

Becks Triad

Answer 12

• distant heart sounds
• increased JVP
• hypotension

Question 13

Ventricular discordance

Answer 13

Pulsus Paradoxus

Kussmauls sign

Question 14

Kussmauls sign

Answer 14

JVD during inspiration

Question 15

Pulsus Paradoxus

Answer 15

Decr. SBP 10 mmHg during inspiration
(impairment of diastolic filling of LV)
*present in 75% of acute cases

Question 16

S/S chronic tamponade

Answer 16

Tachycardia, JVD, hepatomegaly, peripheral edema, increased CVP

Question 17

How to determine pulsus paradoxus?

Answer 17

RR + ABP on monitor - correlate

Question 18

Hemodynamic occurrence in chronic cardiac tamponade

Answer 18

LAP = RVEDP

Question 19

Gold standard for Cardiac Tamponade

Answer 19

Echocardiography

Question 20

CXR - cardiac tamponade

Answer 20

“water bottle heart”

Question 21

Definitive diagnosis of cardiac tamponade

Answer 21

R-sided heart cath

Question 22

Right Sided Heart Cath shows what in cardiac tamponade?

Answer 22

• pressures within cardiac chambers eventually equilibrate.
• confirmed by R-sided heart catheterization.
• PAOP and PADP (both estimates of LA pressure and LVEDP), RAP, and RVEDP will be =

Question 23

Tamponade Tx

Answer 23

• Expand intravascular volume
• isoproterenol - increase contractility/HR
• dopamine - increase SVR
• correct metabolic acidosis
• monitor CVP, Aline
• pericardiocentesis or pericardiostomy

Question 24

What is the anesthetic of choice for pericardiocentesis in a hypotensive patient?

Answer 24

Local anesthetic

*GA = need to resuscitate

Question 25

Goals of induction/maintenance in pt with cardiac tamponade?

Answer 25

Maintain CO/BP

Question 26

What HD changes may occur after pericardiocentesis?

Answer 26

HTN, arrhythmia | Have crash cart nearby + people to help

Question 27

fibrous scarring, adhesions that obliterate pericardial space

Answer 27

chronic constrictive pericarditis | rigid shell around heart - not allowing to beat effectively

Question 28

Causes of chronic constrictive pericarditis

Answer 28

idiopathic - TB/viral/connective tissue dx | previous cardiac surgery, acute

Question 29

s/s chronic constrictive pericarditis

Answer 29

increased CVP + low CO * no other s/s Heart dx * vague symptoms: decreased METs/fatigue

Question 30

diagnosis chronic constrictive pericarditis

Answer 30

echo - normal wall motion with pericardial thickening

Question 31

Tx chronic constrictive pericarditis

Answer 31

"Cardiac Stripping" | -surgical removal of constricting pericardium

Question 32

What HD changes may occur after cardiac stripping?

Answer 32

Slow HD improvement (over 3 months) | -may be d/t atrophy of myocardial fibers, persistent restrictive effects of pericardium

Question 33

Anesthetic management - Cardiac Stripping

Answer 33

Minimize changes in: HR, SVR, venous return, myocardial contractility *benzo +/- opioids optimize pre-op intravasc. volume long case - fluid shifts, blood loss Aline + CVP Dysrhythmias = common *have defibrillator nearby

Question 34

What aspects of the induction of general anesthesia would have detrimental effects on the patient with cardiac tamponade? select 2 A. Peripheral vasodilation from administration of an inhaled anesthetic B. Hypertension due to laryngoscopy C. Increased heart rate during laryngoscopy D. Positive pressure ventilation

Answer 34

A/D - The combination of peripheral vasodilation and myocardial depression from the anesthetic and decreased venous return from positive pressure ventilation can produce severe, life-threatening hypotension in the patient with cardiac tamponade.

Question 35

Which of the following interventions would be appropriate in the management of a patient with symptomatic cardiac tamponade until a pericardiocentesis can be performed? (select four) A. Administering a colloid solution intravenously B. Administering a crystalloid solution intravenously C. Administration of beta blocker to prevent tachycardia D. Administration of isoproterenol to prevent bradycardia E. Administration of atropine to prevent vagal reflexes F. Hypoventilate to create mild to moderate acidosis G. Administer nitroglycerin to decrease SVR H. Performing carotid massage as a temporizing measure

Answer 35

ABDE The primary goals in the management of a patient with symptomatic cardiac tamponade include: expanding intravascular volume by administering crystalloids or colloids, maintaining heart rate and contractility by administering catecholamines (including isoproterenol), administering dopamine to increase systemic vascular resistance if necessary, administering atropine to prevent vagal reactions to the increased intrapericardial pressure, and correcting metabolic acidosis (metabolic acidosis can have detrimental effects on cardiac contractility).

Question 36

What induction agent is most useful for the patient with cardiac tamponade undergoing general anesthesia?

Answer 36

Induction is typically carried out with ketamine because it increases heart rate, contractility, and systemic vascular resistance. A benzodiazepine is often combined with it. The anesthetic may be maintained with nitrous oxide and fentanyl combined with pancuronium, which is useful for its vagolytic effects.

Question 37

Which of the following statements regarding pericarditis is not true A. It produces myocardial depression B. It is often relieved by sitting forward C. It initially produces diffuse ST segment elevation D. It is commonly preceded by a viral infection

Answer 37

A Pericarditis is often due to a viral illness, but may often occur 1-3 days after a myocardial infarction. Deep inspiration worsens the pain. It is often relieved by sitting forward. The ECG changes seen in acute pericarditis occur in four stages. In stage I, there is diffuse ST segment elevation and depression of the PR segment. In stage 2, the ST and PR changes normalize. In stage 3, the T wave inverts, and in stage 4, the T waves normalize. If no other associated pericardial disease is present, acute pericarditis does not alter cardiac function.

Question 38

Which of the following symptoms of cardiac tamponade are indications of ventricular discordance? (select two) A. Beck's triad B. Kussmaul's sign C. Decreased voltage on the electrocardiogram D. Pulsus paradoxus

Answer 38

BD Kussmaul's sign and pulsus paradoxus are both indicative of ventricular discordance (also known as ventricular dyssynchrony) that occurs due to the opposing response of the ventricles to filling during the respiratory cycle.