Overview
Pericarditis is the inflammation of the pericardium, the protective sac around the heart. For EMS providers, recognizing pericarditis is critical because it can lead to serious complications like pericardial effusion or cardiac tamponade.
The condition can be caused by a range of factors, including viral infections, bacterial infections, autoimmune disorders like lupus, trauma, and certain medications.
It may also occur after a myocardial infarction (post-MI pericarditis or Dressler's Syndrome) or be associated with cancer or renal failure. Understanding the causes can help guide treatment and determine how urgent the patient’s condition may be.
Here are some things an EMS Provider needs to know:
Signs and Symptoms
Patients with pericarditis typically present with chest pain that is sharp, stabbing, and pleuritic in nature, meaning it worsens with deep breaths or coughing. A distinguishing feature of pericarditis-related chest pain is that it often improves when the patient sits up and leans forward, and worsens when lying flat. The pain can radiate to the neck, shoulders, or back, which can sometimes mimic the pain of a myocardial infarction.
In addition to chest pain, fever may be present, especially in cases caused by infections. Patients might also experience dyspnea, particularly if pericardial effusion (fluid buildup around the heart) develops.
A classic sign detectable on physical examination is a pericardial friction rub, a scratchy or grating sound heard with a stethoscope near the left sternal border.
EMS Providers may notice widespread ST-segment elevation across multiple leads and PR-segment depression on an EKG, both of which are characteristic of pericarditis.
These combined symptoms can help differentiate pericarditis from other cardiac conditions, such as myocardial infarction.
Prehospital Treatment
Prehospital care for pericarditis focuses on symptom management and preventing complications. Positioning the patient in an upright or leaning-forward posture can relieve pain, and oxygen should be administered if hypoxia or dyspnea is present.
NSAIDs, such as aspirin, if within protocol, can be used to alleviate pain and reduce inflammation.
EKG monitoring is essential to detect any potential changes, such as arrhythmias or signs of tamponade.
Providers should establish IV access for medications or fluid resuscitation, and if cardiac tamponade is suspected (marked by hypotension, jugular venous distention, and muffled heart sounds a.k.a Beck's Triad), rapid transport to a hospital is critical.
Early hospital notification can prepare the receiving facility for advanced care.
In-Hospital Treatment
Once in the hospital, patients with pericarditis will undergo diagnostic testing, including an EKG to assess for pericardial effusion, and other tests such as chest X-rays or bloodwork to identify the underlying cause.
Treatment usually involves anti-inflammatory medications like NSAIDs or colchicine to reduce inflammation and prevent recurrence. In some cases, corticosteroids may be used, but they are typically reserved for autoimmune cases or refractory pericarditis.
Antibiotics are administered if a bacterial infection is identified. If a large pericardial effusion or cardiac tamponade is detected, emergency pericardiocentesis (draining fluid from the pericardium) is necessary.
For recurrent or chronic pericarditis, surgical intervention, such as a pericardiectomy, might be considered.
Key Takeaways for EMS Providers
EMS Providers should be able to recognize pericarditis through its hallmark symptoms, including sharp, pleuritic chest pain and characteristic ECG changes.
Rapid identification and intervention can prevent complications such as cardiac tamponade.
Prehospital care should focus on pain management, patient positioning, and continuous cardiac monitoring, while maintaining a high index of suspicion for worsening conditions.
Prompt transport to a facility equipped for advanced cardiac care is essential, where definitive treatments, such as anti-inflammatory medications or pericardiocentesis, can be administered. Early intervention and effective prehospital management play a key role in patient outcomes.
Further Reading:
Ari D. Leib; Lisa A. Foris; Tran Nguyen; Karam Khaddour (2023) Dressler Syndrome. Treasure Island, Florida: StatPearls Publishing https://www.ncbi.nlm.nih.gov/books/NBK441988/ Accessed September 7, 2024
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