Pericardial disease/ scripts Flashcards by Leslie Mancini

Functions of pericardium

1.stabilize heart within the thoracic cavity
2.protect from traum and infection
3.decrease friction
4. prevent excessive dilation

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Pericarditis

general

Acute inflammation of the pericardium

Hemodynamically stable patient with positional Chest pain ( worse supine/deep inspiration); pericardial friction rub; diffuse ST segment elevation on ECG, new pericardial effusion ( 2 of 4)

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pericarditis

Dx
ECG, cxr, labs

ECG: diffuse ST changes +/- PR prolongation

Cxray: normal unless have effusion
Echocardiogram: r/o effusion

Labs: CBC, ESR, CRP, troponin ( +/- blood cultures, ANA, TB test, Lyme)

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pericarditis

Treatment:
Aspirin 750-1000mg or ibuprofen 600 mg q8 1-2 weeks + Colchicine 0.5 mg po BID x 3 months
Close follow up monitoring symptoms, ECG, CRP

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pericaditis

causes

Idiopathic (86%)( Echovirus and Coxsackie virus most common)
Neoplastic (5.6%)
Tuberculosis (3.9%)
Autoimmune (1.7%)
Purulent (0.9%)

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Acute pericarditis vs Acute MI

ECG changes

Acute Pericarditis
Diffuse ST elevation, rarely exceeds 5 mm
No reciprocal ST segment lead changes
PR depression common

Acute MI
Regional ST elevation, often exceeds 5 mm
ST segment depression in reciprocal leads
Rarely involved PR

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52 yo male presents with acute onset chest wall discomfort “ sharp” worse with cough/deep inspiration; non-radiating; assoc DOE. Leaning forward helps ease symptoms. PMHX: negVS: 148/90, 110, 20 AF
ECG findings?
Echo?

diffuse ST elevation

see if effusion

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Treatment of Pericarditis includes which of the following ?
1- anti-inflammatory rx ( nsaid, colchicine)
2-anti-viral rx
3-antibiotics ( Keflex 500 mg po tid x 14)
4-narcotics

1- anti-inflammatory rx ( nsaid, colchicine)

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Most common side effect of colchine ?
GI upset
Rash
Visual disturbance
swelling

GI upset

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Constrictive Pericarditis

general

Thickened, fibrotic, adherent pericardium reduces elastic properties of myocardium and or intracellular matrix

Kussmal sign: increased JVD w inspiration
Think about the heart having a shell around it

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Constrictive Pericarditis

effects

Restricts diastolic filling
Produces elevated venous pressures

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Constrictive Pericarditis

S/Sx

Progressive dyspnea, fatigue, weakness
Chronic edema, hepatic congestion, ascites
(looks more like HF)

+/- Atrial Fibrillation
Elevated jugular venous pressure ( JVP), kussmaul’s sign

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Constrictive pericarditis

Dx imaging

ECG: no specific changes
Echocardiography: thickened pericardium, septal bounce
Cardiac CT / MRI: thickened pericardium, +/- pericardial effusion
Cardiac Catheterization – confirmatory
Low pulmonary pressures*

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constrictive pericarditis

aggressive diuretics ( consider torsemide or bumetanide if bowel edema)
anti-inflammatories 2-3 months
may require pericardiectomy

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pericarditis

Constrictive vs restrictive

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Pericardial effusion

general

Extra fluid in pericardial space creates pressure on heart chambers when they beat

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Pericardial effusion

Presentation: (6)

Asymptomatic (depends on size/effect)- incidental finding
Constant dull ache, tachycardia, hypotension, JVD, muffled heart sounds
Pulsus paradoxus
dysphagia, dyspnea, hoarseness, hiccups secondary to compression of other structures
Diminished heart sounds, “muffled” heart sounds
Dullness to percussion L lung over angle of scapula (Ewart’s sign)

MUST Rule Out TAMPONADE

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Pericardial Effusion

Dx
ECG, cxray, echo, labs

EKG: low QRS voltage with sinus tach, electrical alternans
Cxray: enlarged cardiac silhouette with clear lungs
Echocardiogram: need to quantify effusion and assess hemodynamic impact
Labs: CBC, CMP, TSH ( +/- ANA), pericardial fluid analysis, poss pericardial bx

Electrical alternans: Changing amplitude of the QRS; caused by the heart swinging in the pericardium

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ECG at admission showing sinustachycardia of 110 beats per minute, low voltage QRS complexes in the anterior leads and no signs of acute ischemia. In retrospect, an electric alternans was seen. Note, the alternating height of the P–QRS–T complexes.

pericardial effusion

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Pericardial Effusion

Tx
Rx, procedure, avoid

Monitor if stable (ECG, pulsus, and serial echo)
Rx: NSAIDs, corticosteroids, colchicine (GI side effect)
Pericardiocentesis for tamponade ( can do at bedside); IVF
Pericardial Window for tamponade
Pericardiectomy for recurrent

avoid vasodilators and diuretics!!!

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what do you avoid with Tx of pericardial effusion?

avoid vasodilators and diuretics!!!

bc youre reducing the pressure within the heart which is bad! you need to counteract the pressure from the effusion

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tamponade vs effusion

tamponade is just a more severe effusion, so severe it is interferring with hearts ability to move, tamponade is not treated with just monitoring like an effusion

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Cardiac Tamponade

general

Study These Flashcards

Medical emergency

Impaired filling pressures impairs cardiac output

Cardiac Tamponade

General

Study These Flashcards

Tachycardia, tachypnea, HYPOTENSION
Narrow pulse pressure
Pulsus paradoxus
Decline of > 10 mm Hg in systolic pressure during inspiration
Elevated JVP
Muffled/distant heart sounds

# Cardiac Tamponade Diagnostic

EKG: low voltage, Sinus Tach Echocardiography: **RV collapse during diastole, dilated IVC**

# Cardiac Tamponade Treatment

Urgent Pericardial window Urgent Pericardiocentesis

58 yo presents ED with Chest Pain, SOB post MVA with airbag deployment. VS: 88/58, 50, 16PE: diaphoretic, elevated JVP, bruising to sternum with diffuse tenderness, distant heart sounds no murmur. Which test will confirm your suspected diagnosis? 1- ECG 2- serial cardiac enzymes 3- stat echocardiogram 4- cxray

3- stat echocardiogram

58 yo presents ED with Chest Pain, SOB post MVA with airbag deployment. VS: 88/58, 50, 16PE: diaphoretic, elevated JVP, bruising to sternum with diffuse tenderness, distant heart sounds no murmur. What finding on ECG corelates with diagnosis (tamponade)? 1- electrical alternans 2-atrial fibrillation 3-diffuse ST elevation 4-ST depression

**1- electrical alternans** 2-atrial fibrillation- arrythmia 3-diffuse ST elevation- pericaditis 4-ST depression - nonstemi

# myocarditis general

Inflammation of myocardium Can be acute or chronic Inflammation can be focal or diffuse Variable presentation

# Myocarditis presentation

Variable!!! Depends on what stage they are in History of infection ,esp viral, within last 30 days Unexplained heart failure, decreased exercise capacity, decline activity tolerance Chest discomfort Arrhythmia ( sinus tach, pac, pvcs)

# Myocarditis S/Sx

Suspect in patients w or w/o cardiac symptoms Rise in troponin Ecg changes consistent w ischemia Arrhythmia Unexplained changes to ventricular function *prodromal stage, looks like MI but theres no bloakcge in cath lab, they had a viral infection..* Seen a lot after COVID

# Myocarditis Treatment Avoid

Supportive care ( **manage HF**, arrhythmia) Activity restriction CM therapies: ACE/ARB/ARNI, BB Cardiac rehab IF COVID-19 systemic anticoagulation Controversial: steroids, IL-6 inhibitors, IVIG, colchicine? **NO NSAIDS!!!**

what do you not give to pt with myocarditis?

NO NSAIDS!!!

# Giant Cell Arteritis general

Aka: Temporal Arteritis or Horton Disease vasculitis of extracranial branches of carotid artery ( temporal, occipital, ophthalmic, and posterior ciliary artery) Associated with polymyalgia rheumatica tends to present with temporal artery involvement- tender to touch

# Giant cell arteritis Presentation

Headache ( usually temporal, UNI-lateral, acute) Jaw claudication Visual changes Acute vision loss Fever, malaise night sweats

# giant cell arteritis PE

Scalp tenderness Thickened temporal artery Signs suggestive of polymyalgia rheumatica

# giant cell arteritis

giant cell arteritis

# Giant cell arteritis Dx

Clinical diagnosis Increased ESR, CRP; possible anemia ( normocytic, normochromic) Temporal Bx - CONFIRMATORY Temporal artery ultrasound: thickening “ halo sign”, stenosis , or occlusion

# giant cell arteritis Tx and complication of disease

High-dose corticosteroids- immediately! Complication is blindness Low dose asa

Components of Script | 6

1.Patient information 2.Name, strength, and dosage form of the drug 3.Directions for use (Sig) 4.Quantity to be dispensed 5.Number of refills 6.Provider information and signature

# Controlled Substance Prescriptions Same as regular prescriptions but must also contain: | 5

1.Days supply 2.Number to be dispensed numerically and alphabetically 3.ICD-10-CM code 4.DEA registration number of prescriber 5.Refills No refills allowed for schedule II controlled substances Only 5 refills allowed for schedule III and IV in a 6th month period Schedule V may be refilled for 1 year from date of issuance

what schedule drugs are required to be electronic only?

Schedule 2

Two patient identifiers are required such as

Name Date of birth Medical record number Address Social Security Number

# pharm abbreviation QHS

every bedtime

# pharm abbreviation QWK

every week

# pharm abbreviation Q4H

every 4 hours

required Provider Information for script | 4

Must contain the printed full name, professional title, and address of the provider Must contain a valid telephone number for the provider Written prescriptions must contain a signature of the provider Controlled substance prescriptions must include the providers DEA number

Physiologic Sx of pain

tachycardia, tachypnea, and hypertension

Behavioral Sx of pain

guarding, grimacing, moaning or grunting, distorted posture, and reluctance to move

3 different categories of pain management

Non-opioid analgesics Opioid analgesics Adjuvant analgesics

# Acetaminophen MOA and indication

Mechanism of action: not fully understood, may be due to activation of descending serotonergic inhibitory pathways in the CNS Indications: Mild to moderate pain, fever

# Acetominophen Max dose and adverse effects

Max dose is 4gram/day Adverse events: typically well tolerated, may see N/V with IV admin

# NSAIDs MOA/ indications/ adverse effects

More than 20 different NSAIDS available for use worldwide Mechanism of action: Inhibit cyclooxygenase(COX 1 and COX2) preventing the production of prostaglandins which cause inflammation, pain, and fever Indication: anti-inflammatory, fever Adverse Events: GI bleed, acute renal failure, hyperkalemia, MI/stroke, neutropenia, thrombocytopenia, TEN or SJS

# Muscle Relaxants general

Typically used for neck and back pain, also reduces muscle spasms and increases mobility of the affected muscles Should be ordered in conjunction with physical therapy, rest, and/or NSAIDs

# muscle relaxants Examples include:

Baclofen Carisoprodol Cyclobenzaprine Metaxalone Methocarbamol Tizanidine

Pericardial disease/ scripts Flashcards

(56 cards)