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44 Cards in this Set
- Front
- Back
How much fluid is notmally in the pericarium?
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10-50 cc
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What is the function of pericardial fluid normally?
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fluid acts as a lubricant to minimize frictional forces between the heart and other structures
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What are the layers of the pericardium and their function?
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1. Fibrous parietal pericardium
- outer layer which provides a protective sac around the heart - to prevent sudden cardiac dilation and minimize bulk cardiac motion 2. Visceral pericardium - inner layer - intimately related to the surface of the heart |
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Congenital Pericardial Abnormalities
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Pericardial Cysts
Absence of Pericardium: Partial or Total - Usually diagnosed with CT or MRI - Associated with atypical chest pain or sudden death |
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Do pericardial cysts require intervention?
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No.
They are benign. |
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What is the most common clinical pathologic process involving the pericardium?
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acute pericarditis
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What are potential etiologies of acute pericarditis?
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1. infectious
2. non-infectious 3. hypersensitivity pericarditis |
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Causes of Infectious Pericarditis
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Viral pericarditis is the most common cause of pericarditis
- Viral (coxsackie A & B, echovirus, mumps, adenovirus, HIV) - Mycobacterium tuberculosis - Bacterial (Pneumococcus, Streptococcus, Staphylococcus, Legionella) - Fungal (histoplasmosis, coccidioidomycocis, candidiasis, blastomycosis) |
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Prognosis associated with bacterial pericarditis
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VERY BAD
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Causes of Non-infectious Pericarditis
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Idiopathic
Neoplasm - Metastatic (lung, breast, melanoma, lymphoma) - Primary (mesothelioma) Renal Failure/Uremia associated with hemodialysis Irradiation Myocardial Infarction Hypothyroidism Aortic Dissection Chylopericardium (thoracic duct injury) Trauma - Post-pericardiotomy - Chest wall injury/trauma |
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Causes of Hypersensitivity Pericarditis
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- Collagen Vascular Disease (systemic lupus erythematosus, rheumatoid arthritis, scleroderma, acute rheumatic fever)
- Drug Induced (procainamide, hydralazine, isoniazid) - Post Myocardial Infarction or Cardiac Surgery - Dressler’s Syndrome(late presentation... more of an autoimmune reactive process) |
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Acute Pericarditis
Physical Exam |
- resting tachycardia
- low-grade fever (if infectious etiology) - pericardial friction rub on auscultation (classically triphasic, but may be biphasic or monophasic) |
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Acute Pericarditis
Chest Pain |
- usually sudden and severe in onset
- with viral pericarditis, usually 1-2 weeks after “viral illness” - retrosternal or left precordial pain - may refer to back or trapezius - pain may be preceded by low-grade fever - may be pleuritic - may be positional - worse with supine position; relieved with upright posture |
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ECG Findings in Acute Pericarditis
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* diffuse ST-segment elevation in early stage
* depression of the PR segment - T wave inversion in late stage - low voltage in QRS (if large pericardial effusion) - electrical alternans (if large pericardial effusion) - atrial fibrillation *Most Useful diagnostic tool |
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electrical alternans
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magnitude of QRS varies with every heart beat ... can be seen with swinging heart in pericardial effusion
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Is laboratory blood work useful in acute pericarditis?
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NO
- elevated erythrocyte sedimentation rate - eleveated white blood cell count |
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Is acute pericarditis always visualized with echocardiography?
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NO
depends on the amount of pericardial effusion |
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What are the epicardial leads on ECG?
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1
2 aVL AVF V3-V6 |
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What are the endocardial leads on ECG?
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aVR
V1 sometimes V2 |
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What is the treatment for Acute Pericarditis?
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- If no significant pericardial effusion, then treatment is targeted toward symptoms - usually with NSAIDs
- If peri-infarct pericarditis, then may prefer high dose aspirin (650 mg BID-QID) - Steroids for resistant pericarditis (txs sxs, but has dependence problems) - Colchicine for resistant pericarditis (Dr. Hoyle prefers this over steroids) |
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Pericardial Effusion
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- All forms of pericardial disease may lead to excess fluid accumulation in the pericardial space.
- Any etiology for pericarditis is a potential cause for a pericardial effusion. - Large effusions which accumulate slowly (wks - mos) may be asymptomatic; rapidly (days) accumulating smaller effusions may lead to cardiac tamponade. |
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Types of Fluid in Pericardial Effusion
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Serosanguinous effusions (blood-tinged fluid)
- neoplasm, Tb, uremia, idiopathic, non-infectious cause Hemopericardium (blood) - trauma, myocardial rupture, aortic dissection, coronary artery rupture Purulent effusion (pus) - secondary to direct invasion of the pericardial space by infectious organisms |
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Pericardial Effusion
Diagnosis |
ECHOCARDIOGRAPHY - imaging procedure of choice
- size and location - characteristics of effusion - e.g. presence of fibrin, clot, tumor, calcium Chest Radiograph - cardiomegaly or “water-bottle” shape ECG - low voltage, if large effusion |
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Cardiac Tamponade
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Cardiac tamponade is a clinical spectrum ranging from mild increases in pericardial pressure to profound hemodynamic collapse.
accumulation of fluid in pericardial space --> increase in pericardial pressure --> cardiac compression resulting in IMPAIRED DIASTOLIC VENTRICULAR FILLING (throughout diastole) of RV --> decrease RV output = decrease LV preload ---> depresses CO --> Cardiogenic Shock |
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Cardiac Tamponade
Slinical Presentation |
Presentation may mimic heart failure: Dyspnea on exertion and orthopnea
- Tachycardia and tachypnea - Jugular venous distention - Hypotension and poor peripheral perfusion - Shock and profound hemodynamic collapse - Pulsus Paradoxus |
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Cardiac Tamponade
Diagnosis |
- Clinical Presentation
- ECG - sinus tachycardia, electrical alternans - Echocardiography - signs of increased pericardial pressure - Cardiac Catheterization (not needed for dx) |
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Cardiac Tamponade
Treatment |
Supportive Measures:
- Keep BP high to avoid shock... IV fluids, pressors (NE, Epi, dopamine) Remove the fluid - pericardiocentesis -surgical pericardectomy |
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Pulsus Paradoxus
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Big variation (greater than 10 mmHg) in systolic pressure between inspiration and respiration
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What are the common causes of Constrictive Pericarditis
*Important to know |
- neoplasm
- tuberculosis - histoplasmosis - MEDIASTINAL RADIATION - purulent or RECURRENT PERICARDITIS - rheumatoid arthritis - uremia - CARDIAC SURGERY - anything that can cause pericarditis... can take days to years to develop |
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Constrictive Pericarditis
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- Results from dense fibrosis and adhesion of the parietal and visceral layers
- Creates a rigid “case” around the heart - EARLY ventricular filling is UNIMPEDED, but diastolic filling is subsequently abruptly reduced as a result of the inability of the ventricles to fill secondary to the restraints imposed by a rigid, thickened, and calcified pericardium (DECREASED LATE DIASTOLIC FILLING). |
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Constrictive Pericarditis
Presentation |
- Right heart failure
- weakness, dyspnea, orthopnea, anorexia - peripheral edema, hepatomegaly, splenomegaly, ascites, prominently descent with jugular venous pressures - “Kussmaul’s sign” - “pericardial knock” |
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Kussmaul's Sign
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JVD filling with inspiration
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Pericardial Knock
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characteristic abnormal heart sound in diastole (after S2) for Constrictive Pericarditis
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Constrictive Pericarditis
Diagnosis |
Chest X-ray
- pericardial calcification Echocardiography - signs of ventricular interdependence - respiratory variation in left and right ventricular filling Chest CT or MRI - pericardial thickening CT - pericardial calcification Cardiac catheterization |
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Constrictive Pericarditis
Treatment |
surgical stripping of the pericardium
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What can constrictive pericarditis be confused with?
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restrictive cardiomyopathy
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Constrictive Pericarditis
Prognosis |
Poor Prognosis
Natural history: - slow decline of cardiac output - progressive renal and hepatic failure. |
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What is the main difference between cardiac tamponade and constrictive pericarditis?
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- Constrictive pericarditis does not have early diastolic filling dysfunction ... only late
- whereas Cardiac Tamponade has diastolic dysfunction for the whole of diastole |
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What is the preferred method of pericardiocentesis?
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ECHO-GUIDED (only 10% relapse)
Others: - surgical - cardiac cath lab |
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What are the types of cardiac trauma?
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Penetrating injury - usually bullet or stab injury
Non-penetrating injury - usually deceleration injuries |
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Cardiac Trauma
Penetrating Injury |
- usually result in hemopericardium with tamponade or exsanguination.
- May have associated cardiac damage such as traumatic valvular regurgitation, intracardiac shunts, and coronary artery injuries. Treatment: immediate thoracotomy for life-threatening hemorrhage or tamponade |
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What is the most common cardiac manifestation of blunt trauma?
THIS IS A QUESTION!!! |
CARDIAC CONTUSION
leads to: - new arrhythmias or ECG changes - LV wall motion abnormality on echo |
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What are less common manifestation of blunt trauma?
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- traumatic ventricular septal rupture
- myocardial rupture and/or pseudoaneurysm formation - coronary artery trauma - valvular regurgitation - pulmonary artery rupture |
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What happens in Traumatic Transection of the Descending Thoracic Aorta?
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Descending aorta remains fixed b/c of ligamentum arteriosum
But heart and ascending aorta move… result in transection of aorta |