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Terms in this set (41)
What are the two parts of the pericardium? Where are each of them located?
Parietal pericardium: inner part of the sac; Visceral pericardium: surface of the heart.
Pericardial sac normal contains ___ mL of serous fluid
15 to 50
Accumulation of pericardial fluid under high pressure is called ___. The outcome depends on three factors: what are they?
Outcome depends on: volume of fluid, rapidity of accumulation, and compliance of pericardial sac.
What are some non-inflammatory pericardial effusions?
: Increased hydrostatic pressure (CHF), increased capillary permeability (severe myxedema), decreased plasma oncotic pressure
Others: Blood (hemopericardium), Air (pneumopericardium), Lymph (chylopericardium), Exogenous materials
What are three potential causes of hemopericardium?
1. Trauma (can be iatrogenic)
2. Ventricular rupture following MI
3. Aortic dissection with rupture into pericardial sac.
What are three causes of pneumopericardium?
1. Trauma (positive pressure ventilation especially in neonates, asthma, penetrating chest injuries)
2. Fistula formation (between pericardium and air containing structure)
3. Gas producing organism (C. perfringens)
What are three types of causes of pericarditis?
1. Infectious agents (viruses, pyogenic bacteria, TB, fungi, others)
2. Immune-mediated (rhumatic fever, SLE, scleroderma, postcardiotomy, post MI-Dressler, drug hypersensitivity)
3. Miscellaneous (MI, uremia, neoplasia, trauma, irradiation)
Name three types of acute pericarditis. What is each group characterized by?
: Thin fluid derived from plasma or produced by mesothelial cells. Low protein content, few neutrophils, lymphocytes, histiocytes.
: with increase in vascular permeability, large molecules (fibrinogen) pass vascular barrier with formation of fibrin. Increased numbers of neutrophils.
: characterized by numerous acute inflammatory cells, fibrin and edema.
Usually, a friction rub is present, Caused by acute MI, uremia, chest radiation, SLE, trauma. Some degree of fibrinous reaction is almost routine after cardiac surgery. What am I? What syndromes might I experience?
Dressler syndrome: a few weeks after a transmural MI (probably immune)
Postpericardiotomy syndrome: similar to Dressler syndrome
My heart looks like bread with butter that has been dropped on a shaggy rug and lifted. What am I?
I am a pericarditis almost always due to infectious agents. What am I? What is the most common infectious agent? How do these agents gain access to the pericardium?
Usually bacterial agent.
Gains access via: bloodstream, direct extension from heart, lungs, pleura, mediastinum, surgery or trauma, lymphatics
Describe how hemorrhagic pericarditis is different than hemopericardium.
Hemopericardium: pure blood in pericardium.
Hemorrhagic pericarditis: blood usually mixed with fibrinous or purulent exudate. Causes: TB, metastatic tumor, bleeding diathesis, pyogenic infectious agents (rarely), postoperative. Cytology may be useful if caused by a tumor.
What can cause caseous pericarditis?
TB or fungi
Due to spread from mediastinal or tracheobronchial lymph nodes. See extensive fibrosis as part of chronic healing (constriction often results)
How do you know it's healed pericarditis?
Organization with various amounts of fibrosis and calcification. Adhesions may form from visceral to parietal pericardium obliterating the pericardial space
I can be a consequence of constrictive pericarditis. What am I?
Adhesive mediastinopericarditis. More extensive adhesions form after radiation, surgery, suppuration or caseation. May obliterate the sac and parietal layer may adhere to surrounding structures. Increased cardiac work with energy expended in retracting structures.
Concretio cordis. What am I? What am I caused by? How am I treated?
Severe constrictive pericarditis. THe heart is encased in dense, fibrous scar tissue, usually with calcification (hard as a rock). HIstory of prior pericarditis may or may not be present. Diastolic filling is impaired.
Caused by: idiopathic, infection (TB, gram +/- bacteria), radiation, cardiac surgery, autoimmune disorders, drugs, neoplasms.
Only treatment is SURGICAL.
T/F: Pericardial tumors are rarely metastatic.
FALSE. USUALLY metastatic.
Rarely, mesothelioma; only rare documentation of asbestos exposure. Sarcomas are extremely rare. Other primary tumors: teratoma, fibroma, lipoma, angioma, lymphoma
Absence of the pericardium usually involves the (Left/Right/Both) side(s) and is usually innocuous.
Usually Left side.
RARE reports of sudden death in partial defects due to strangulating herniation of a portion of the heart. Sometimes associated with other cardiac defects.
What are some common clinical features of acute pericarditis?
Pleuritic chest pain, fever, pericardial friction rub, EKG: diffuse ST elevation, PR segment depression.
What is the most common cause of acute pericarditis?
Pleuritic chest pain (when take a deep breath--pain changes with inspiration). Fever and pericardial friction rub that sounds like a washing machine. What do I have?
What are the three components of a pericardial friction rub?
1. Atrial or pre-systolic component
2. Ventricular systolic component (loudest)
3. Ventricular diastolic component.
MOST commonly heard after open heart surgery.
What are three causes of ST elevation?
Stretch the outside of the heart: Transmural MI, Aneurysm in LV, OR epicardial inflammation (pericarditis)
T/F: An echocardium of pericarditis will always show fluid and diagnose pericarditis.
FALSE. Absence of pericardial effusion DOES NOT rule out pericarditis. Pericarditis is a clinical diagnosis, NOT an echo diagnosis!
Can do other blood tests: PPD, RF, ANA (lupus), viral titers (take days to come back)
Search for malignancy if there are no other known causes.
Pericardiocentesis ONLY for relief of tamponade (low diagnostic yield)
How do we treat pericarditis?
Pain relief: anti-inflammatory drugs (ASA/NSAID's, Colchicine--treated for gout too)
Steroids for recurring pericarditis (sparingly because increased incidence of relapse)
Antibiotics/drainage for purulent pericarditis
Dialysis for uremic pericarditis
Neoplastic: XRT, chemotherapy
Why don't we see uremic pericarditis anymore?
Treat patients much better for kidney problems--dialized before this happens.
I am yellow and serous or serofibrinous. I am more likely a (viral/malignant) effusion.
Viral. Malignant effusions are usually hemorrhagic.
T/F: Small effusions can still produce hemodynamic abnormalities.
What are some symptoms from hemodynamic abnormalities caused by effusions?
FALSE. Do not produce hemodynamic abnormalities.
Large effusions cause hemodynamic compromise and may lead to compression of adjoining structures and produce symptoms of:
1. dysphagia (compression of esophagus)
2. Hoarseness (recurrent laryngeal nerve compression)
3. Hiccups (diaphragmatic stimulation)
4. Dyspnea (pleural inflammation/effusion)
I have a large effusion and am experiencing muffled heart sounds, (increased/reduced) intensity of rub, and Ewart's sign. What is Ewart's sign?
REDUCED intensity of rub.
Ewartz: compression of lung leading to an area of consolidation in the left infrascapular region (atalectasis/compression of lung tissue, detected as dullness to percussion and bronchial breathing)
Fluid under high pressure compresses the cardiac chambers. What am I? What are my two types?
Cardiac tamponade--more likely affects diastole.
Acute: trauma, LV rupture--may not be very large
Gradual: large effusion, due to any etiology of acute pericarditis
Which part of the heart is most likely to collapse from pressure from cardiac tamponade? During what part of the cardiac cycle?
RA during diastole.
What are some common symptoms during cardiac tamponade? Explain why you get those.
Impaired diastolic filling of both ventricles
Decreased SV and CO: hypotension/shock and reflex tachycardia
Increased venous pressures:
Systemic: JVD, hepatomegaly, ascites, peripheral edema
Pulmonary congestion: rales
Note: more R HF than L)
Pulsus paradoxus. What am I? When do you see me? How do you measure me?
Decreased in systolic pressure (BP) during inspiration >10 mmHg (normally only <10 mmHg). Seen with cardiac tamponade.
Measured with sphingomonometer (BP cuff). Normal breathing. Slowly bring down BP cuff until hear first sound. Will hear intermittent pressure (Karokoff sounds). As continue to bring the cuff down, start hearing more. Once get all the way down, will hear much more frequent sounds--every beat. The difference between these two would be pulsus paradoxis.
What are some of the major findings from R heart catheterization for cardiac tamponade?
Elevated RA and RV diastolic pressures; equalized diastolic pressures
Blunted y descent in RA tracing
(y descent: early diastolic filling--atrial emptying)
Decreased BP and pulsus paradoxus
Pericardial pressure=RA pressure
Blunted y-descent and pulses paradoxus. What do I have?
Blunted y-descent represents decreased atrial emptying into ventricles (because of compression by high pericardial pressure)
How do we treat cardiac tamponade?
Pericardiocentesis, leave in a pericardial window; Balloon pericardial pericardiotomy
If cardiac tamponade continues over a long period of time, what can you get?
Constrictive pericarditis (fibrous scar formation, fusion of pericardial layers, calcification further stiffens pericardium).
On physical exam, what would you see from constrictive pericarditis?
Increased HR, Decreased BP
Ascites, edema, hepatomegaly
Early diastolic "knock" after S2, sudden cessation of ventricular diastolic filling imposed by rigid pericardial sac
Kussmaul's sign (increased Jugular venous pressure during inspiration)
What is Kussmaul's sign? When would I see it?
Increased Jugular venous pressure during inspiration
As a patient with constrictive pericarditis inhales, RA pressure (increases/decreases) while pulmonary capillary wedge pressure (increases/decreases)
RA pressure increases.
What is the difference between constrictive pericarditis and restrictive cardiomyopathy?
Physiologically and hemodynamically, VERY similar physical findings. Constrictive pericarditis is AROUND the heart; restrictive CM is the heart itself.
Constrictive pericarditis is treated with surgery to remove the pericarditis
Restrictive CM: treat the underlying disease
BOTH may see Kussmaul's sign, low voltage,
Restrictive: Increased wall thickness for restrictive CM...
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