Pericardial Diseases and Cardiac Trauma

• 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)

• 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

• Salicylates or NSAIDs
• Steroids for further tx

• 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).

• 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.

• Minimze changes in HR, SVR, venous return, and contractility
• Maintenance: Combo of opioids bentos, and N2O with or w/o volatiles.

Blood from aortic or cardiac injury can fill the pericardial space and cause cardiac tamponade