Pericardial disease/ scripts Flashcards
Functions of pericardium
4
1.stabilize heart within the thoracic cavity
2.protect from traum and infection
3.decrease friction
4. prevent excessive dilation
Pericarditis
general
PE
Acute inflammation of the pericardium
Hemodynamically stable patient with positional Chest pain ( worse supine/deep inspiration); pericardial friction rub; diffuse ST segment elevation on ECG, new pericardial effusion ( 2 of 4)
pericarditis
Dx
ECG, cxr, labs
ECG: diffuse ST changes +/- PR prolongation
Cxray: normal unless have effusion
Echocardiogram: r/o effusion
Labs: CBC, ESR, CRP, troponin ( +/- blood cultures, ANA, TB test, Lyme)
pericarditis
Tx
Treatment:
Aspirin 750-1000mg or ibuprofen 600 mg q8 1-2 weeks + Colchicine 0.5 mg po BID x 3 months
Close follow up monitoring symptoms, ECG, CRP
pericaditis
causes
Idiopathic (86%)( Echovirus and Coxsackie virus most common)
Neoplastic (5.6%)
Tuberculosis (3.9%)
Autoimmune (1.7%)
Purulent (0.9%)
Acute pericarditis vs Acute MI
ECG changes
Acute Pericarditis
Diffuse ST elevation, rarely exceeds 5 mm
No reciprocal ST segment lead changes
PR depression common
Acute MI
Regional ST elevation, often exceeds 5 mm
ST segment depression in reciprocal leads
Rarely involved PR
52 yo male presents with acute onset chest wall discomfort “ sharp” worse with cough/deep inspiration; non-radiating; assoc DOE. Leaning forward helps ease symptoms. PMHX: negVS: 148/90, 110, 20 AF
ECG findings?
Echo?
diffuse ST elevation
see if effusion
Treatment of Pericarditis includes which of the following ?
1- anti-inflammatory rx ( nsaid, colchicine)
2-anti-viral rx
3-antibiotics ( Keflex 500 mg po tid x 14)
4-narcotics
1- anti-inflammatory rx ( nsaid, colchicine)
Most common side effect of colchine ?
GI upset
Rash
Visual disturbance
swelling
GI upset
Constrictive Pericarditis
general
Thickened, fibrotic, adherent pericardium reduces elastic properties of myocardium and or intracellular matrix
Kussmal sign: increased JVD w inspiration
Think about the heart having a shell around it
Constrictive Pericarditis
effects
Restricts diastolic filling
Produces elevated venous pressures
Constrictive Pericarditis
S/Sx
Progressive dyspnea, fatigue, weakness
Chronic edema, hepatic congestion, ascites
(looks more like HF)
+/- Atrial Fibrillation
Elevated jugular venous pressure ( JVP), kussmaul’s sign
Constrictive pericarditis
Dx imaging
ECG: no specific changes
Echocardiography: thickened pericardium, septal bounce
Cardiac CT / MRI: thickened pericardium, +/- pericardial effusion
Cardiac Catheterization – confirmatory
Low pulmonary pressures*
constrictive pericarditis
Tx
aggressive diuretics ( consider torsemide or bumetanide if bowel edema)
anti-inflammatories 2-3 months
may require pericardiectomy
pericarditis
Constrictive vs restrictive
Pericardial effusion
general
Extra fluid in pericardial space creates pressure on heart chambers when they beat
Pericardial effusion
Presentation: (6)
Asymptomatic (depends on size/effect)- incidental finding
Constant dull ache, tachycardia, hypotension, JVD, muffled heart sounds
Pulsus paradoxus
dysphagia, dyspnea, hoarseness, hiccups secondary to compression of other structures
Diminished heart sounds, “muffled” heart sounds
Dullness to percussion L lung over angle of scapula (Ewart’s sign)
MUST Rule Out TAMPONADE
Pericardial Effusion
Dx
ECG, cxray, echo, labs
EKG: low QRS voltage with sinus tach, electrical alternans
Cxray: enlarged cardiac silhouette with clear lungs
Echocardiogram: need to quantify effusion and assess hemodynamic impact
Labs: CBC, CMP, TSH ( +/- ANA), pericardial fluid analysis, poss pericardial bx
Electrical alternans: Changing amplitude of the QRS; caused by the heart swinging in the pericardium
ECG at admission showing sinustachycardia of 110 beats per minute, low voltage QRS complexes in the anterior leads and no signs of acute ischemia. In retrospect, an electric alternans was seen. Note, the alternating height of the P–QRS–T complexes.
pericardial effusion
Pericardial Effusion
Tx
Rx, procedure, avoid
Monitor if stable (ECG, pulsus, and serial echo)
Rx: NSAIDs, corticosteroids, colchicine (GI side effect)
Pericardiocentesis for tamponade ( can do at bedside); IVF
Pericardial Window for tamponade
Pericardiectomy for recurrent
avoid vasodilators and diuretics!!!
what do you avoid with Tx of pericardial effusion?
avoid vasodilators and diuretics!!!
bc youre reducing the pressure within the heart which is bad! you need to counteract the pressure from the effusion
tamponade vs effusion
tamponade is just a more severe effusion, so severe it is interferring with hearts ability to move, tamponade is not treated with just monitoring like an effusion
Cardiac Tamponade
general
Medical emergency
Impaired filling pressures impairs cardiac output
Cardiac Tamponade
General
Tachycardia, tachypnea, HYPOTENSION
Narrow pulse pressure
Pulsus paradoxus
Decline of > 10 mm Hg in systolic pressure during inspiration
Elevated JVP
Muffled/distant heart sounds
Cardiac Tamponade
Diagnostic
EKG: low voltage, Sinus Tach
Echocardiography: RV collapse during diastole, dilated IVC
Cardiac Tamponade
Treatment
Urgent Pericardial window
Urgent Pericardiocentesis
58 yo presents ED with Chest Pain, SOB post MVA with airbag deployment. VS: 88/58, 50, 16PE: diaphoretic, elevated JVP, bruising to sternum with diffuse tenderness, distant heart sounds no murmur.
Which test will confirm your suspected diagnosis?
1- ECG
2- serial cardiac enzymes
3- stat echocardiogram
4- cxray
3- stat echocardiogram
58 yo presents ED with Chest Pain, SOB post MVA with airbag deployment. VS: 88/58, 50, 16PE: diaphoretic, elevated JVP, bruising to sternum with diffuse tenderness, distant heart sounds no murmur.
What finding on ECG corelates with diagnosis (tamponade)?
1- electrical alternans
2-atrial fibrillation
3-diffuse ST elevation
4-ST depression
1- electrical alternans
2-atrial fibrillation- arrythmia
3-diffuse ST elevation- pericaditis
4-ST depression - nonstemi
myocarditis
general
Inflammation of myocardium
Can be acute or chronic
Inflammation can be focal or diffuse
Variable presentation
Myocarditis
presentation
Variable!!! Depends on what stage they are in
History of infection ,esp viral, within last 30 days
Unexplained heart failure, decreased exercise capacity, decline activity tolerance
Chest discomfort
Arrhythmia ( sinus tach, pac, pvcs)
Myocarditis
S/Sx
Suspect in patients w or w/o cardiac symptoms
Rise in troponin
Ecg changes consistent w ischemia
Arrhythmia
Unexplained changes to ventricular function
prodromal stage, looks like MI but theres no bloakcge in cath lab, they had a viral infection.. Seen a lot after COVID
Myocarditis
Treatment
Avoid
Supportive care ( manage HF, arrhythmia)
Activity restriction
CM therapies: ACE/ARB/ARNI, BB
Cardiac rehab
IF COVID-19 systemic anticoagulation
Controversial: steroids, IL-6 inhibitors, IVIG, colchicine?
NO NSAIDS!!!
what do you not give to pt with myocarditis?
NO NSAIDS!!!
Giant Cell Arteritis
general
Aka: Temporal Arteritis or Horton Disease
vasculitis of extracranial branches of carotid artery ( temporal, occipital, ophthalmic, and posterior ciliary artery)
Associated with polymyalgia rheumatica
tends to present with temporal artery involvement- tender to touch
Giant cell arteritis
Presentation
Headache ( usually temporal, UNI-lateral, acute)
Jaw claudication
Visual changes
Acute vision loss
Fever, malaise night sweats
giant cell arteritis
PE
Scalp tenderness
Thickened temporal artery
Signs suggestive of polymyalgia rheumatica
giant cell arteritis
giant cell arteritis
Giant cell arteritis
Dx
Clinical diagnosis
Increased ESR, CRP; possible anemia ( normocytic, normochromic)
Temporal Bx - CONFIRMATORY
Temporal artery ultrasound: thickening “ halo sign”, stenosis , or occlusion
giant cell arteritis
Tx and complication of disease
High-dose corticosteroids- immediately!
Complication is blindness
Low dose asa
Components of Script
6
1.Patient information
2.Name, strength, and dosage form of the drug
3.Directions for use (Sig)
4.Quantity to be dispensed
5.Number of refills
6.Provider information and signature
Controlled Substance Prescriptions
Same as regular prescriptions but must also contain:
5
1.Days supply
2.Number to be dispensed numerically and alphabetically
3.ICD-10-CM code
4.DEA registration number of prescriber
5.Refills
No refills allowed for schedule II controlled substances
Only 5 refills allowed for schedule III and IV in a 6th month period
Schedule V may be refilled for 1 year from date of issuance
what schedule drugs are required to be electronic only?
Schedule 2
Two patient identifiers are required such as
Name
Date of birth
Medical record number
Address
Social Security Number
pharm abbreviation
QHS
every bedtime
pharm abbreviation
QWK
every week
pharm abbreviation
Q4H
every 4 hours
required Provider Information for script
4
Must contain the printed full name, professional title, and address of the provider
Must contain a valid telephone number for the provider
Written prescriptions must contain a signature of the provider
Controlled substance prescriptions must include the providers DEA number
Physiologic Sx of pain
tachycardia, tachypnea, and hypertension
Behavioral Sx of pain
guarding, grimacing, moaning or grunting, distorted posture, and reluctance to move
3 different categories
of pain management
Non-opioid analgesics
Opioid analgesics
Adjuvant analgesics
Acetaminophen
MOA and indication
Mechanism of action: not fully understood, may be due to activation of descending serotonergic inhibitory pathways in the CNS
Indications: Mild to moderate pain, fever
Acetominophen
Max dose and adverse effects
Max dose is 4gram/day
Adverse events: typically well tolerated, may see N/V with IV admin
NSAIDs
MOA/ indications/ adverse effects
More than 20 different NSAIDS available for use worldwide
Mechanism of action: Inhibit cyclooxygenase(COX 1 and COX2) preventing the production of prostaglandins which cause inflammation, pain, and fever
Indication: anti-inflammatory, fever
Adverse Events: GI bleed, acute renal failure, hyperkalemia, MI/stroke, neutropenia, thrombocytopenia, TEN or SJS
Muscle Relaxants
general
Typically used for neck and back pain, also reduces muscle spasms and increases mobility of the affected muscles
Should be ordered in conjunction with physical therapy, rest, and/or NSAIDs
muscle relaxants
Examples include:
Baclofen
Carisoprodol
Cyclobenzaprine
Metaxalone
Methocarbamol
Tizanidine
