Special Operations Forces Medical Handbook

4-6

Follow-up Actions
Wound Care: Clean and dress any wounds appropriately.
Return evaluation: Daily BP checks after initial lowering until resolution of end organ ndings. If evidence
of end organ damage is present or worsening, additional medications not available in the eld will be needed
to treat the member.
Evacuation/Consultation Criteria: Progression of neurologic decits, CHF or anuria should prompt urgent
consultation and evacuation if possible.

Cardiac: Pericarditis

CAPT Kurt Strosahl, MC, USN

Introduction: Acute pericarditis is inflammation of the pericardial sac surrounding the heart that results in
chest pain. The majority of cases are idiopathic or post-viral. Other causes are acute myocardial infarction,
uremia, bacterial infection, tuberculosis, collagen-vascular disease, neoplasm (lung, breast, melanoma,
lymphoma, leukemia) or trauma.

Subjective: Symptoms
Precordial chest pain with a pleuritic component (worse when breathing in and out), pain is worse lying down
and better sitting up or leaning forward, fever, shortness of breath on exertion or rest, fatigue and malaise.

Objective: Signs
Using Basic Tools: Pericardial friction rub (squeaky leather sound) loudest leaning forward on held
expiration; diaphoresis, pallor, neck vein distension greater than 5cm above the sternal notch; possible pleural
rub (sound of Velcro). A 10 mm or greater difference in the systolic BP between inspiration and expiration
(pulsus paradoxicus) suggests tamponade.
Using Advanced Tools: EKG: Diagnostic ST elevation in most leads and PR depression in II, III, aVf.
Lab: WBC >15 suggests infectious cause; urinalysis showing protein and casts suggests uremic cause.

Assessment:

Differential Diagnosis
Pleurisy - pleural rub without pericardial rub or EKG abnormality
Aortic dissection - different pulse pressures between the arms
Pulmonary embolism - typically unilateral calf tenderness and swelling consistent with phlebitis
Pneumothorax - absence of breath sounds on one side is typical
Acute Myocardial Infarction - EKG shows typical ST elevation in 2 or more contiguous leads, not all leads
Pericardial tamponade - falling BP with rising neck veins and signs of hypovolemic shock

Plan:
Treatment
Primary: Rest. ASA 650 mg po q 4-6 hours or ibuprofen 800 mg tid or indomethacin 50mg po tid. Perform
pericardiocentesis for tamponade (see Procedure: Pericardiocentesis).
Alternative: Prednisone 60 mg po qd
Primitive: Morphine: Titrate dosage beginning at 2mg IV and repeating q 5 minutes, until pain relief without
over-sedation
Empiric: If bacterial infection is suspected, the most common cause is staph. Give nafcillin 2 gm q 4 hours
plus gentamicin 1mg/kg IV q 8 hours.

Patient Education
General: Inflammation of the pericardial sac is often idiopathic or viral and self-limiting over 5-7 days.
Pericarditis is not life threatening unless fluid starts to accumulate in the sac. Exertion, even though it hurts,
will not worsen the condition.