4.1 H Cvs Disorders Of Pericardium Em Cam239

Front 1

A better term for pericarditis

Back 1

Perimyocarditis

Front 2

Regarding pericarditis which is incorrect
1 pain does not generally radiate to the arms
2 dyspnoea is a feature
3 sinus tachycardia is common
4 a transient, migratory pericardial rub is best herd in the patient leaning forward in full expiration, at the left eternal edge

Back 2

2 NOT a feature

Front 3

Regarding pericarditis causes which is incorrect
1 malignancy causes approximately 5% of cases
2 25% of cases are idiopathic, probably viral
3 MI may cause pericarditis both acutely and several weeks t months later (Dressler's syndrome)
4 myxoedema is a cause
5 penicillin hypersensitivity may cause

Back 3

1 25%

Other causes include viral and bacterial causes, uraemia, autoimmune and connective tissue diseases, dissecting aneurysms

Front 4

Regarding ECG changes in myocarditis which is incorrect
1 ECG changes are due to the associated epimyocarditis hence may be normal in 'pure' pericarditis
2 PR segment depression may occur without ST elevation
3 ST elevation may be focal or localised
4 in stage 1 and 3 the ECG may appear normal
5 TW changes may be permanent

Back 4

4 incorrect, in stages 2 and 4 may appear normal

Front 5

Regarding pericarditis which is incorrect
1 diagnosis is usually clinical however the absence of a rub despite typical pain should be followed closely
2 rest is essential as exercise may complicate an associated myocarditis
3 echocardiography should be performed in all cases
4 inpatient treatment should be undertaken if high fever, subacute onset or immunosuppression
5 inpatient treatment should be undertaken if recent trauma, oral anticoagulant Rx, large effusion
6 follow up us essential to monitor for development of myocarditis, chronicity, constrictive pericarditis

Back 5

3 controversial, but as per Cameron 'if a significant effusion is suspected' it should be performed

Front 6

Differentiating BER from pericarditis

Back 6

Both have concave upwards STE
BER usually precordial, v2-5
ST:T wave ratio usually SMALLER in BER e.g. In V6 <25%, in pericarditis usually >25%
BER may have notch/slurring at j point
Absence pr depression in BER, Spodicks's sign

Front 7

Regarding cardiac tamponade management, in which circumstances would you first use...
1. a subxiphoid window/pericardotomy
2. Needle pericardiocentesis - ED
3. Fluoroscopic guided pericardiocentesis - Cath lab
4. Thoracotomy

Back 7

1. Preferred option in stable patient, ESP if purulent, recurrent, or tissue needed for dx (except diagnoses in 4)
2. Last resort, pre-arrest or just arrested patient (except dx of 4 - thoracotomy is still preferred, esp for dissection when attempted drainage may be detrimental)
3. Alternative to subxiphoid window
4. MI with myocardial free wall rupture, Aortic dissection type A, trauma

Front 8

Regarding cardiac tamponade, effusion may be caused by any of the causes of pericarditis. What are the other aetiologies?
When is 200ml the limit of fluid accommodation, and when is 2L? How much is needed to be observed on CXR?

Back 8

Trauma
MI with myocardial free wall rupture
Dissecting aortic aneurysm type A
Coagulation disorders

200ml = any acute cause
2L = any chronic cause
250mL - hence acutely CXR may often be NORMAL

Front 9

What is 'compensated' cardiac tamponade, and how might it be dx?

Back 9

No clinical signs, dx on echo findings

Front 10

Regarding cardiac tamponade which is incorrect
1 commonest sx is dyspnoea
2 Beck's triad is nonspecific, but sensitive
3 the differential dx includes PE, tension pneumothorax, air embolism, right ventricular infarct
4 the gold standard investigation is echo
5 CT and MRI detect pericardial fluid, but are insensitive for TAMPONADE

Back 10

1 correct - 87-89% sensitive
2 incorrect - muffled HS, hypotension and increased JVP is neither sensitive nor specific
3 correct, and svc obstruction, chronic constrictive pericarditis, severe Ccf, cardiogenic shock, and extra pericardial compression (haematoma, tumour)

Front 11

Regarding cardiac tamponade the definitive treatment is drainage. What are the other limited aspects of treatment?

Back 11

Oxygenation
Ventilation if necessary, beware may cause significant drop in CO due to impaired cardiac filling from positive intrathoracic pressure
Inotropes usually ineffective
Treat cause (e.g reverse anti coagulation)
HDU/ICU admission if clinically compensated prior to definitive drainage procedure

Front 12

Regarding myocarditis which is incorrect
1 development of chronicity and dilated cardiomyopathy is uncommon
2 the clinical spectrum ranges from asymptomatic subclinical disease to fulminant cardiac failure, shock and sudden cardiac death
3 diagnosis is difficult and usually clinical
4 malignancy, chronic renal failure (uraemia) and hypothyroidism may all be implicated
5 presentation may be similar to MI

Back 12

1 correct - a possible sequlae but most are benign and fully recover
4 incorrect - these are causes of pericarditis NOT myocarditis. Causes of myocarditis include viruses, bacteria (usually atypical), Protozoa, toxins (including etoh and clozapine), immune mediated
5 correct - Chest pain, raised biomarkers, ECG changes

Front 13

Definitive diagnosis is not possible in ED as requires endomyocardial biopsy. What is the commonest scenario that would suggest myocarditis? What investigations might support the dx?

Back 13

Young patient, new CCF, shock, arrhythmia, no other cause. ECG with st/t wave changes, CXR with CCF or cardiomegaly, raised inflammatory markers, echo with global wall motion abnormalities, effusion or ventricular cavity dilation and reduced ejection fraction

Front 14

Regarding myocarditis which is incorrect?
1 strict bed rest is advised because exercise has been shown to increase the degree of myocyte necrosis
2 cardiac transplant may ultimately be required
3 no competitive sport for 6 months after onset is recommended
4 diuretics, vasodilators, inotropes and ACE inhibitors/angII antagonists all have a role
5 ECMO and left ventricular assist devices have no role

Back 14

5 incorrect, may provide a bridge to transplant or recovery