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 Medication Administration - Intravenous (IV) Catheter Complications

EMS Providers need to be aware of the potential complications associated with IV catheter placement, their presentations, and how to manage them.

Here’s an overview:

1. INFILTRATION

Definition: Leakage of IV fluid into the surrounding tissue.

Presentation:

• Swelling at the insertion site
• Coolness to the touch
• Pallor (pale skin)
• Discomfort or pain

Management:

• Discontinue the IV immediately.
• Elevate the affected limb.
• Apply a warm or cold compress based on patient comfort and solution infiltrated.

2. EXTRAVASATION

Definition: Leakage of vesicant (irritating) fluids into the surrounding tissue.

Presentation:

• Similar to infiltration, but with more severe symptoms
• Pain or burning at the site
• Blistering or tissue necrosis

Management:

• Stop the IV immediately.
• Elevate the limb and apply a cold compress.
• Notify medical control for further treatment recommendations, which may include specific antidotes.

3. OCCLUSION

Definition: Blockage of the IV catheter, preventing fluid flow.

Presentation:

• Difficulty or inability to infuse fluids
• Backflow of blood into the IV line

Management:

• Check for kinks or clamps on the tubing.
• Attempt to flush the catheter gently.
• If occlusion persists, discontinue and restart IV at a different site.

4. HEMATOMA

Definition: Collection of blood outside the vessel due to vein damage during insertion.

Presentation:

• Swelling and bruising at the insertion site
• Tenderness and discoloration

Management:

• Apply direct pressure to the site to stop bleeding.
• Apply a cold compress to reduce swelling.
• Avoid using the same site for subsequent IV attempts.

5. CATHETER SHEAR

Definition: A rare but serious complication where part of the catheter breaks off inside the vein.

Presentation:

• Sudden pain during insertion or movement of the catheter
• Potential for embolization of the catheter fragment

Management:

• Avoid using excessive force during insertion.
• If suspected, discontinue IV immediately and contact medical control for further instructions, which may include imaging to locate the fragment.

6. VASOVAGAL REACTIONS

Definition: Reflex reaction to pain or anxiety causing sudden drop in heart rate and blood pressure.

Presentation:

• Dizziness or lightheadedness
• Nausea
• Pale skin and sweating
• Fainting or near fainting

Management:

• Lay the patient flat and elevate the legs.
• Loosen any tight clothing.
• Provide reassurance and monitor vital signs.

7. PHLEBITIS

Definition: Inflammation of the vein.

Presentation:

• Redness and warmth along the vein
• Tenderness or pain at the site
• A palpable cord-like vein

Management:

• Discontinue the IV.
• Apply a warm compress.
• Use anti-inflammatory medications if appropriate.

8. INFECTION

Definition: Introduction of bacteria at the insertion site, potentially leading to local or systemic infection.

Presentation:

• Redness, warmth, and swelling at the site
• Purulent drainage
• Fever and chills (systemic infection)

Management:

• Discontinue the IV.
• Clean the site and cover with a sterile dressing.
• Notify medical control for possible antibiotic treatment.

PREVENTION TIPS

• Aseptic Technique: Always use aseptic technique during insertion.
• Proper Site Selection: Choose an appropriate site and avoid joints or areas with poor circulation.
• Securement: Secure the catheter well to prevent movement.
• Monitoring: Regularly check the IV site for signs of complications.

By recognizing and managing these complications promptly, EMS Providers can ensure patient safety and improve outcomes during IV therapy.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

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

Hantke, J (2022) IV Placement and Management. Appropedia. Accessed May 22, 2024.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

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