Pericarditis/Myocarditis/Endocarditis Flashcards
What surrounds, protects and holds the heart in place?
Pericardium
what part of the pericardium is the Tough, inelastic and outer connective tissue
Fibrous pericardium
What is the Thinner, delicate and forms double layer around the heart? What are the layers?
Serous pericardium
- Parietal layer
- Visceral layer (on the heart itself touching the epicardium of the heart).
What is the Thinner, delicate and forms double layer around the heart? What are the layers?
Serous pericardium
- Parietal layer
- Visceral layer (on the heart itself touching the epicardium of the heart).
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.
Pericarditis means
inflammation of the pericardium
Pericarditis is mostly caused by what and what demographic?
viral infections
males < 50 years old
What are the most common organisms related to pericarditis?
Coxsackieviruses and Echovirus
Pericarditis Bacterial etiologies:
Small pox vaccine, Neisseria gonorrhea,
Chlamydia, Mycoplasma, and Lyme
Differential Diagnosis’s for acute pericarditis
(1) AMI
(2) PE
(3) Pericardial effusion
(4) Myocarditis
(5) Aortic dissection
(6) Pleurisy (with pleural friction rub)
(7) Pneumonia
What are S/S for Pericarditis?
- Substernal chest pain which is usually pleuritic (sharp), possible radiation to neck, shoulder, or arm.
- Pain is worse when supine and relieved by sitting up and leaning
- Fever
How would acute pericarditis present in your PE
Pericardial friction rub is most common sign (sounds like Velcro/crunching snow).
What labs/rads/testing would you do for acute pericarditis?
- CBC may have elevated WBC due to infection and inflammation
- Cardiac enzymes will be elevated if due to myocarditis
- CXR to evaluate for pneumonia or widened mediastinum.
- EKG: diffuse ST-segment elevation
Viral pericarditis Meds
(a) Aspirin 325-650 mg every 6 hours
(b) NSAIDS (Indomethacin, Motrin or Naproxen) for up to 3 weeks.
Can you keep pericarditis a patient on ship?
If stable can stay on ship
if they do not show signs of improvement or s/s worsen EVAC
What are some complications for pericarditis?
(1) Pericardial effusion
(2) Pericardial Tamponade
What are the Three layers of the heart wall?
Epicardium
Myocardium
Endocardium
What is defined as inflammation of the myocardium?
Myocarditis
Myocarditis is caused by what Viral agents?
Influenza, Epstein Barr, Hepatitis B, HIV.
Myocarditis is caused by what bacterial agents.
Beta-Hemolytic strep (cause of Rheumatic fever), Lyme, Neisseria meningitides
What are some non-infectious causes for myocarditis?
(a) Alcohol
(b) Cocaine
(c) Medications: PCN, cephalosporin, sulfonamides, diuretics.
(d) Insect bites
(e) Snake bites
(f) Inflammatory bowel disease
(g) Celiac disease
(h) Sarcoidosis
True/false
Myocarditis is never accompanied by pericarditis
False
it can be frequently accompanied by pericarditis due to the large amount of inflammation spreading out to the pericardium
Symptoms and Physical Findings for what?
(1) Fever
(2) SINUS TACHYCARDIA out of proportion to TEMPATURE
(3) Retrosternal chest pain
(4) Excessive fatigue or exercise intolerance.
(5) S3, S4
(6) Pericardial friction rub if pericarditis is also present.
(7) Clinical illness may overshadow clinical signs of myocardial dysfunction.
Myocarditis
Differential Diagnosis for Myocarditis
(1) AMI
(2) Unstable angina
(3) PE
(4) Aortic dissection
(5) Esophageal rupture
(6) Pericarditis
(7) Pericardial effusion
(8) Pneumonia
What labs/Studies/EKG would you order for suspected myocarditis
- CARDIAC ENZYMES (troponin, CK-MB) will be positive .
- CBC: Will have an elevated WBC because of infection and inflammation.
- ESR or Sedimentation rate (marker of inflammation) will be elevated.
- C-reactive protein (marker of inflammation) will be elevated.
- EKG: May show signs of pericarditis with diffuse ST-segment elevation.
- Echocardiogram is performed in all patients to look at heart function
- Cardio MRI
- endomyocardial biopsy for DX
What labs will distinguish between Myocarditis and Pericarditis?
CARDIAC ENZYMES
(troponin, CK-MB) will be positive
In severe cases of (pericarditis/myocarditis) signs of progressive congestive heart failure may be seen.
Myocarditis
Endocarditis/Pericarditis/Myocarditis
SINUS TACHYCARDIA out of proportion to TEMPATURE
Myocarditis
Myocarditis or pericarditis S/S
Fever
both
Myocarditis or pericarditis S/S
Pericardial friction rub
Mainly pericarditis….
bothish…..
can be in myocarditis if pericarditis is also present
Myocarditis or pericarditis
Give Nsaids
Pericarditis
True/False
Nsaids are an effective treatment for myocarditis
FALSE!!!!!!!!!!!!! =[
AVOID NSAIDS
is not effective and can worsen heart failure
symptoms if they have them
Endocarditis/Pericarditis/Myocarditis
- Stabilize and transfer to higher level of care
- Initiate Morphine therapy for pain.
- Restrict activity if cannot get them to a higher level of care right away
Myocarditis
Treatment for idiopathic and viral myocarditis
supportive and symptom directed
Rest, fluids, pain control with morphine
True/false
Meningococcemia or Rheumatic fever give antibiotics
true
Endocarditis/Pericarditis/Myocarditis
Substernal chest pain is worse when supine and relieved by sitting up and leaning
pericarditis
Endocarditis/Pericarditis/Myocarditis
EKG: diffuse ST-segment elevation
pericarditis
what is a bacterial or fungal infection of the valvular or endocardial surface of the heart?
Endocarditis
Native valve endocarditis is usually caused by what
Staph Aureus
Streptococci.
In IV Drug users ______ infection accounts for 60% of cases.
Staph Aureus
IV drug users typically present with (Right or Left) sided endocarditis vs other causes usually affect (Right or left) sided valves.
- Right
2. Left
True/ false
Endocarditis takes Days to weeks to get symptoms
True
Symptoms/Physical Findings of what?
- Fever
- Non-specific symptoms (cough, dyspnea, arthralgias, abdominal, back, or flank pain).
- Characteristic peripheral lesions caused by emboli
- New onset heart murmur
Endocarditis
True/false
ANY new heart murmur with a fever is Endocarditis until proven otherwise
True
Endocarditis/Pericarditis/Myocarditis
Strokes and major systemic events in 25% of patients, occurring before or within the first week of antibiotic therapy.
Endocarditis
endocarditis
what are the Characteristic peripheral lesions caused by emboli:
- Petechia on palate, conjunctiva, or beneath finger nails.
- Splinter hemorrhages: Red, linear streaks under nail plate and within nail bed.
- Janeway lesions: Painless (micro-abscesses), erythematous lesions on palms and soles.
- Osler’s nodes: Painful (immune-complex depositions).
- Roth spots: Exudative lesions in the retina; occurs in 25% of patients
what are some Differential Diagnosis for endocarditis
(1) Skin and soft tissue infection
(2) Osteomyelitis
(3) Meningitis
(4) Pneumonia
(5) Sepsis
(6) Myocarditis
(7) Pericarditis
(8) Cardiomyopathy
what Labs/Studies/EKG would you order for suspected endocarditis
(1) Blood cultures
(2) CBC with differential
(3) Chemistry to evaluate of kidney damage.
(4) EKG: Non-diagnostic, new conduction abnormalities suggest myocardial abscess formation.
(5) Echocardiogram: Gold standard to evaluate for valvular vegetations.
Endocarditis
True/ false
Since blood cultures are positive in 90% of patients it is not acceptable to await blood culture results before initiating antibiotics.
False
it is acceptable to
await blood culture results before initiating antibiotics.
Endocarditis Empiric therapy if patient is septic would be
Ertapenem 1 gram IV q24 hours
or
Vancomycin 1 gram IV q12 hours
plus Ceftriaxone 2 grams IV daily.
Initial Care for endocarditis
(1) IV, O2 if saturation < 94%, Monitor.
(2) 3 sets of blood cultures.
(3) Transfer to higher level of care.
