EMS Cardiac Emergencies - Pericarditis

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  Accessed September 7, 2024

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson.

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell.

Xanthopoulos, A. & Skoularigis, J. (2017) Diagnosis of Acute Pericarditis. Journal of Cardiology Practice #15. Accessed September 6, 2024

EMS Trauma Emergencies - Thoracic Injuries

The "Deadly Dozen" is a term used in emergency medicine and prehospital care to refer to a list of twelve potentially life-threatening chest injuries. 

EMS Providers need to be familiar with these injuries because prompt recognition and appropriate management are crucial for the survival and well-being of the patient. 

Here are the Deadly Dozen Chest Injuries and why they are important for EMS providers to know about:

1. Lung Contusion: A lung contusion is a bruising of lung tissue caused by chest trauma, leading to impaired gas exchange and respiratory distress. Monitoring for signs of respiratory compromise is crucial.

2. Tracheobronchial Injury: Trauma to the trachea or bronchi can lead to airway compromise and respiratory distress. EMS providers should maintain a high index of suspicion for this injury in patients with chest trauma.

3. Diaphragmatic Injury: A diaphragmatic injury can lead to herniation of abdominal contents into the chest, causing respiratory compromise and other complications. EMS providers should be aware of the potential signs and manage accordingly.

4. Esophageal Injury: Trauma to the chest can cause damage to the esophagus, leading to leakage of gastric contents into the chest cavity. EMS providers should be vigilant for signs of mediastinitis and infection.

5. Open Pneumothorax (Sucking Chest Wound): An open wound in the chest allows air to enter the pleural space, leading to a pneumothorax. It can impair ventilation and lead to respiratory distress. EMS providers must apply airtight seals to manage it.

6. Tension Pneumothorax: This occurs when air accumulates in the pleural space and compresses the lung, causing pressure on the heart and other vital structures. It can lead to cardiovascular collapse and requires immediate intervention, such as needle decompression.

7. Massive Hemothorax: This injury involves the accumulation of blood in the pleural space, which can impair lung function and cause hypovolemic shock. It may result from chest trauma, and EMS providers need to identify and manage it.

8. Flail Chest: A flail chest occurs when a segment of the ribcage becomes detached due to multiple rib fractures. It can impair ventilation and lead to respiratory failure. Stabilization and pain management are essential.

9. Cardiac Tamponade: This is a condition where blood or fluid accumulates in the pericardial sac, compressing the heart and impairing its function. It can cause hemodynamic instability and requires immediate intervention.

10. Aortic Disruption: Trauma can cause a tear or rupture in the aorta, which can lead to massive internal bleeding and shock. Early recognition and rapid transport are essential.

11. Myocardial Contusion: Blunt chest trauma can lead to a bruising or injury to the heart muscle, causing arrhythmias, myocardial infarction, or heart failure. EMS providers need to monitor for signs of cardiac injury.

12. Pulmonary Contusion: Similar to lung contusion, pulmonary contusion involves bruising of lung tissue, which can lead to impaired gas exchange and respiratory distress. EMS providers should monitor for signs of respiratory compromise.

EMS providers need to be aware of these chest injuries and their potential consequences because early recognition and appropriate management can be life-saving. 

Proper assessment, stabilization, and rapid transport to a medical facility for definitive care are critical in the prehospital setting for patients with these injuries.