Page 466 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

336 PART 3: Cardiovascular Disorders

limited the routine use of these drugs. Since most cases of FES are mild Pericardial Disease
and the great majority of patients recover, an acceptable prophylactic CHAPTER
regimen would have to be quite safe and inexpensive. If using prophy- Paul Sorajja
lactic steroids, low dose methylprednisolone (1.5 mg/kg every 8 hours 40
for 6 doses) appears to be equally efficacious to higher doses. 210
Once the syndrome becomes evident, treatment is that of ARDS (see
Chap. 52). Prevention of reembolization by fracture fixation should be
attempted, and supportive management with oxygen and PEEP initiated. KEY POINTS
It has been suggested that corticosteroids may be of benefit even once
the syndrome is established, but evidence is at the level of individual • The diagnosis of acute pericarditis should be made on the basis of
213
case reports, and we do not recommend them. No clear role has been typical chest pain symptoms, the presence of a pericardial friction
established for glucose and insulin, heparin, ethanol, and albumin, rub, and electrocardiographic abnormalities, which are distinctive
despite studies seeking a useful therapy for FES. from changes due to myocardial ischemia.
• Although a comprehensive evaluation is usually warranted in
patients with acute pericarditis, the diagnostic yield is low with
KEY REFERENCES causes identified in less than 20% of patients.
• Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of • High-dose nonsteroidal anti-inflammatory drugs (NSAIDs) and
pulmonary embolism. A controlled trial. Lancet. June 18, 1960; adjunctive colchicine are effective medical therapy for acute
1(7138):1309-1312. pericarditis, except in episodes due to acute coronary syndromes
• Dalen JE, Alpert JS. Natural history of pulmonary embolism. Prog where NSAIDs are contraindicated.
Cardiovasc Dis. January-February 1975;17(4):259-270. • Pulsus paradoxus is a bedside finding of cardiac tamponade that
• Jerjes-Sanchez C, Ramirez-Rivera A, de Lourdes Garcia M, arises from compromise in left ventricular stroke volume during
inspiration and a subsequent fall in stroke volume.
et al. Streptokinase and heparin versus heparin alone in massive
pulmonary embolism: a randomized controlled trial. J Thromb • Echocardiography is the primary diagnostic modality for tamponade.
Thrombolysis. 1995;2(3):227-229. Signs include diastolic inversion or collapse of the right atrium and
• Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota right ventricle, ventricular septal shifting with respiration, enlarge-
ment of the inferior vena, and respiratory variation in transmitral flow.
AJ. Antithrombotic therapy for venous thromboembolic disease:
American College of Chest Physicians Evidence-Based Clinical • In patients in whom invasive monitoring is available (eg, Swan-
Practice Guidelines (8th ed.). Chest. June 2008;133(suppl 6):454S-545S. Ganz catheter) cardiac tamponade manifests as blunting or
• Kreit JW. The impact of right ventricular dysfunction on the absence of the y descent, elevation in filling pressures, tachycardia,
and reduced cardiac output.
prognosis and therapy of normotensive patients with pulmonary
embolism. Chest. April 2004;125(4):1539-1545. • The diagnosis of constrictive pericarditis can be made with
• Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients echocardiography in most patients, with invasive catheterization
reserved for patients in whom the clinical findings and noninva-
with intermediate-risk pulmonary embolism. N Engl J Med. sive studies cannot definitively establish the diagnosis.
2014;370:1402-1411.
• PIOPED_investigators. Value of the ventilation/perfusion scan in
acute pulmonary embolism. Results of the prospective investiga-
tion of pulmonary embolism diagnosis (PIOPED). The PIOPED
Investigators. JAMA. May 23-30, 1990;263(20):2753-2759. In the vast majority of patients with constrictive pericarditis, cardiac
surgery with pericardiectomy is the definitive treatment for relief of
• Simonneau G, Sors H, Charbonnier B, et al. A comparison of low- heart failure.
molecular-weight heparin with unfractionated heparin for acute The pericardium is a fibroelastic sac comprised of parietal and visceral
pulmonary embolism. The THESEE Study Group. Tinzaparine layers that normally contain 15 to 50 mL of plasma ultrafiltrate. Pericardial
ou Heparine Standard: evaluations dans l'Embolie Pulmonaire. disorders can be broadly categorized into the clinical entities of acute
N Engl J Med. September 4, 1997;337(10):663-669. pericarditis (with or without effusion), cardiac tamponade, and constric-
• Stein PD, Beemath A, Matta F, et al. Clinical characteristics of tive pericarditis.
patients with acute pulmonary embolism: data from PIOPED II.
Am J Med. October 2007;120(10):871-879. ACUTE PERICARDITIS
• Stein PD, Fowler SE, Goodman LR, et al. Multidetector computed
tomography for acute pulmonary embolism. N Engl J Med. June 1, Acute pericarditis may occur in isolation or as part of a systemic disor-
2006;354(22):2317-2327. der. Although there are a variety of etiologies, the majority of cases are
idiopathic or presumed to be viral or autoimmune in origin. In devel-
• Ternacle J, Gallet R, Mekontso-Dessap A, et al. Diuretics in nor- oping countries and susceptible individuals, tuberculosis and human
motensive patients with acute pulmonary embolism and right immunodeficiency virus are common causes of acute pericarditis.
ventricular dilatation. Circ J. 2013;77:2612-2618.
• Wells PS, Anderson DR, Ginsberg J. Assessment of deep vein ■ DIAGNOSIS
thrombosis or pulmonary embolism by the combined use of The diagnosis of acute pericarditis is made on the basis of typical chest
clinical model and noninvasive diagnostic tests. Semin Thromb pain symptoms, the presence of a pericardial friction rub, distinctive
Hemost. 2000;26(6):643-656. electrocardiographic abnormalities, and supportive data from non-
invasive testing. The clinical presentation is characterized by chest
pain in 90% to 95% of cases, with additional symptoms attributable
REFERENCES to the underlying etiology. Chest pain due to acute pericarditis is
typically anterior and sharp, with aggravation related to maneuvers that
Complete references available online at www.mhprofessional.com/hall increase pericardial pressure (eg, cough, inspiration, orthostasis). These

section03.indd 336 1/23/2015 2:07:40 PM