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Unit VI Promoting Health in Patients With Circulatory or Perfusion Disorders
Heart
Normal pericardium
Parietal pericardium
Pericardial fluid
Visceral pericardium
Inflamed pericardium
FIGURE 30.5 Inflammation of the pericardium in pericarditis.
Pericardium
Medications Medication management goals are to alleviate pain and stop the inflammatory process. Aspirin, ibuprofen, indo- methacin, and other NSAIDs are indicated. Colchicine may be used as an additional anti-inflammatory medication with NSAIDs. If pain or inflammation is not relieved by NSAIDs, corticosteroids may be used. IL-1 blockers such as anakinra are newer agents that are being studied more. Additional treatment may be warranted depending on the etiology of the disease. For example, in addition to the use of anti-inflammatory agents, antimicrobial therapy may be instituted for bacterial pericarditis. Complications A complication of pericarditis is pericardial effusion. This is an accumulation of fluid in the pericardial space exceed- ing the typical 20 to 60 mL. Pericardial effusion is diag- nosed by the use of chest x-ray, echocardiography, and ECG. Depending on the volume and clinical presentation, draining of the excess fluid, also known as pericardiocen- tesis , may be indicated. In a pericardiocentesis procedure, ultrasound guides needle insertion through the chest wall to aspirate the excess fluid. Depending on the etiology, pericardial fluid may accumulate slowly (i.e., neoplastic), allowing the pericar- dium to stretch to accommodate the increased volume. Clinical symptoms in these cases gradually progress. In contrast, rapidly growing effusions overwhelm the stretching capacity of the pericardium, resulting in an acute decompensation. If not treated emergently, the increased volume of fluid within the pericardial space can exert pressure on the heart, resulting in cardiac tam- ponade. In cardiac tamponade , the excessive fluid in the pericardial sac compresses the cardiac structures and dramatically decreases cardiac output. Common signs
The sound of a pericardial friction rub is a result of the fric- tion between the inflamed layers of the pericardium when the heart moves within the pericardial sac. It is best heard over the left sternal border at the end of expiration with the patient leaning forward. It produces a high-pitched, scratchy noise and is muffled when excessive fluid is present. Box 30.1 How to Assess Pericardial Friction Rub
Interprofessional Management Medical Management Diagnosis Diagnostic Tests
Tests used to diagnose pericarditis include ECG, chest x-ray, cardiac CT scan, and CMR imaging. The hallmark ECG changes include widespread ST-segment elevation or PR-segment depression (Fig. 30.6) occur in about 60% of patients. The finding of cardiomegaly and clear lung fields on chest x-ray may indicate a pericardial effusion (fluid buildup in the pericardial sac) and might be support- ive of the pericarditis diagnosis. Pericardial effusion might also be evident on an echocardiogram, CT scan, or CMR. Laboratory tests include serial cardiac biomarkers to rule out MI. Positive blood cultures, a complete blood count with a high WBC count, and positive inflammatory markers such as C-reactive protein or sedimentation rates may indicate the presence of infection or inflammation, leading to the diagnosis of pericarditis when combined with the associated clinical manifestations.
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