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Common responses to pericardial Injury
- Acute Pericarditis
- Pericardial Effusion
- Constrictive Pericarditis
- Cause: Viral infection
- Acute benign pericarditis: transient and uncomplicated clinical course.
- Can occur after an MI (Dressler's syndrome is a delayed acute pericarditis)
Acute Pericarditis Diagnosis
- Chest pain worsening with inspiration and is relieved by leaning forward
- Friction Rub: occurs throughout the cardiac cycle
- Stage 1: Diffuse ST elevation and PR depression
- Stage 2: Normalization of the ST and PR segments
- Stage 3: Widespread T wave inversion
- Stage 4: Normalization of the T waves
Acute Pericarditis Treatment
- Salicylates or NSAIDs
- Steroids for further tx
Pericardial Effusion and Cardiac Tamponade
- Pericardial fluid accumulates in the pericardial cavity
- Tamponade: occurs when pressure of the fluid in the pericardial space impairs cardiac filling.
- Fluid: transudative or exudative (seroanguineous)
- S/S: depends on size and duration. Normal pericardial space holds 15ml of plasma ultra filtrate.
- Spectrum of hemodynamic abnormalities of varying severity
- S/S: Increased CVP, pulses paradoxus, equalization of cardiac filling pressures, hypotension, decreased voltage on the ECG, activation of the SNS
- Large effusions: compression of esophagus, trachea, and lungs w/ anorexia, dyspnea, couch, and chest pain.
- Kussmaul's sign: distention of the jugular veins during inspiration
- Pulsus paradoxus: slight and irregular pulse disappearing during inspiration and returning during expiration (decrease of systolic >10mm Hg during inspiration).
- Ventricular discordance: dyysynchrony or opposing response of the R/LV to filling during the respiratory cycle.
- Beck's triad (33% of pts): quiet heart sounds, increased jugular venous pressure, and hypotension.
- Tx: fluid removal, temporizing measures (expand intravascular volume, catecholamines, and correcting metabolic acidosis).
Cardiac Tamponade Anesthesia
- GA and PPV can result in life-threatening hypotension (vasodilation, myocardial depression, or decreased venous return).
- Pericardiocentesis under local anesthesia is preferred
- Induction: Ketamine or Benzo w/ N2O, relaxation (pancuronium)
- Anticipate the change from hypotension to hypertension following release of severe tamponade.
- Chronic: fibrous scarring and adhesions that create a rigid shell around the heart
- Acute: fibroelastic constriction.
- S/S: Increased CVP and low CO due to lack of diastolic filling of the heart. Signs often mimic RV failure w/o pulmonary congestion. AFib is a common manifestation. Kussmaul's sign is common however pulses paradoxus is not.
- ECG: nonspecific, minor changes.
Constrictive Pericarditis Anesthesia
- Minimze changes in HR, SVR, venous return, and contractility
- Maintenance: Combo of opioids bentos, and N2O with or w/o volatiles.
Pericardial and Cardiac Trauma
Blood from aortic or cardiac injury can fill the pericardial space and cause cardiac tamponade