1. Layers of the Heart… Pericardial & Myocardial Disease Ashlea Wilmott PGY-1 FRCPC Emergency Medicine

2. Pericarditis Pericardial Effusion Tamponade

8. WBC Trop ESR/CRP CK, CK-MB Lytes BUN Creat Urine and Serum tox

12. StageTime FrameEKG Findings 1First hours- days -Diffuse ST elevation (concave up) -Reciprocal ST depression in aVR and V1 -Elevated PR segment in aVR and depression of PR elsewhere (highly specific) 2Variable-Normalization of ST and PR segments -T wave flattening 3Variable-Diffuse T wave inversions -May not be seen in some patients 4Weeks -months-Normalization -May have persistent T wave inversions

14. EKG Findings PericarditisMI ST segment elevation -Begins at the J point -Rarely >5mm -Retains concavity -Typical pattern is convex -Can exceed 5mm in height Distribution-Generalized-Vessel distribution Sequence-ST and T wave findings are NOT simultaneous -Simultaneous Normalization-Generally a longer process Morphology-Each lead has its own characterization -Vessel distribution of ST evolution PR depression-Common-Rare Pathologic Q wave -Rare-Common Arrhythmia-Rare-Common

15. EKG Findings PericarditisBenign Early Repolarization ST segment elevation -Begins at the J point -Rarely >5mm -Retains concavity -Begins at the J point -Maintains normal configuration Distribution-Generalized-Most common V3-V6 PR depression-Common-Uncommon Evolution of change -Very Common-Uncommon ST elevation to T wave amplitude ratio in V6 ->0.24-<0.24

16. Benign Early Repolarization

18. + LR 5.4

21. Causes of Pericarditis P Post MI (Dressler’s Syndrome) E Exocrine (Myexdema) R Radiation induced I Infectious C Collagen Vascular Disease A Amyloidosis, Anticoagulation, Aneurysm (dissection) R Renal failure D Drugs – The 5 P’s Penicillin, phenytoin, procainamide, pressure (hydralazine), pulmonary (INH) I Idiopathic, Idiopathic Thrombocytopenic Purpura T Trauma, Tumors (malignancy) I Infective endocarditis with ring abscess S Sarcoidosis

22. Infectious

29. PERICARDIALPERICARDIAL EFFUSIONEFFUSION

31. TAMPONADE……

32. Signs and Symptoms of Cardiac Tamponade

33. Symptoms of Cardiac Tamponade SymptomSensitivity (%) Dyspnea87-89 Fever25 Chest pain20 Cough7-10

34. SignFrequency (%) Elevated Neck Veins100 Tachycardia81-100 Systolic BP > 10058-100 Pulsus Parodoxus >10mmHg98 Pulsus Parodoxus > 20mm Hg78 Pulsus Parodoxus >30mm Hg49 Diminshed heart sounds36-84 Hepatomegaly58 Signs of Cardiac Tamponade

35. SignSensitivity (%) Pulsus paradoxus >10 mm HG82 + LR 3.3 Tachycardia77 Elevated JVP76 Diminished heart sounds28 Hypotension26 Hypertension33 Peripheral edema21-28 Kussmaul26

36. Sensitivity 89% - JAMA

38. EKG Findings of Cardiac Tamponade FindingSensitivity (%) Low voltage EKG42 Atrial arrhythmia6 Electrical alternans16-21 ST elevation18-30 PR depression18

40. Pericardiocentesis

41. Constrictive Pericarditis

42. Myocardial Disease

43. The Cardiomyopathies

46. Coxsackie B Adenovirus

49. Cardiac Enzymes