A 35 y/o female presents with sharp chest pain which was of sudden onset some 10 days ago. The pain has been less intense over the past week, but worse with inspiration. Two months ago she had a tick bite while hiking in New England. There is a biphasic high pitched squeaky sound at the left sternal border, louder with expiration and leaning forward. EKG is shown.
What might have been seen on the EKG 8 to 10 days ago?
•EKG as would have shown, earlier in the course of the disease. Note PR segments.
1.What position causes the pain to be aggravated in the patient who suffered a tick bite 2 weeks prior?
Pericardial pain is pleuritic and postural (worse supine, relieved by sitting). It also tends to be substernal and may be associated with dyspnea, fever and rub.
What is the most common cause of this type of EKG change?
Causes: Usually viral (coxsackie or echo), though may be TB (subacute with night sweats, etc), bacterial (toxic), uremia (shaggy/hemorrhagic and exudative), neoplastic (tamponade), Inflammatory reaction/Dresslers (increased SR; days to several mo after MI or surgery), radiation (usually first year), drugs (clozapine), myxedema (cholesterol crystals), and autoimmune (SLE).
Three weeks later the patient develops the following EKG and complains of exertional dyspnea and orthopnea. PE reveals basilar crackles and an occasional rubbing sound over the precordium. The patient has now developed a (an):
B. pericardial tamponade.
C. constrictive pericarditis.
Myocarditis - patient is presenting with CHF and Heart Block
What would the tick bite patient noticed very early on in the disease progression?
What comes after Early localized Lyme disease?
Note: Bilateral Bell’s palsy. Other causes of bilateral cranial nerve palsies are TB, sarcoid and trauma.
What is the treatment for Pericarditis?
Pulsus paradoxus with inspiratory drop in systolic pressure. This can
also be seen in constrictive pericarditis, asthma and COPD as well.
A jugular venous tracing is shown on the above patient. What is causing the change in the “y” wave?
a = atrial contraction
x = atrial relaxation
v = atrial filling
y = atrial emptying
Pericardial Tamponade is characterized by intrapericardial pressures of > 15 mmHg which restricts venous return and ventricular filling.
acv waves showing lack of y descent can be seen in the LA via
measuring wedge pressures.
What could you see on a Cardiac ECHO in Cardiac Tamponade
Treatment for Cardiac Tamponade
*Marker for constrictive pericarditis, more so than cardiac tamponade.
In constrictive pericarditis the jugular engorges with inspiration. This is referred to as the Kussmaul sign. (This sign can also be positive in severe COPD, pulmonary hypertension with RV failure, and more rarely in cardiac tamponade).
What is the characteristic of the JVP wave in a patient with CP?
Tricuspid opens and blood rushes in. THere is so much pressure the blood slams in to the ventricle but then meets a steel wall and stops.
result is a sharp descent and plateaus bc no more blood can get into the heart and creats a "M" or "W" wave pattern w/CP
What kind of wave forms do expect to see with constrictive pericarditis?
What other signs are found in constrictive pericarditis?
What is the arrow pointing to?
What is going on in these wave forms
What can simulte Costrictive Pericarditis?
How does one differentiate CP from restrictive heart disease?
Treatment for Constrictive Pericarditis?
Summarize Cardiac Tamponade and Constrictive Pericarditis