01Approach to the Critical Patient/attcp61

Immediate priorities

›Airway, breathing, circulation threats

›Hemodynamic instability

›SBP < 90 mmHg

›Sinus tachycardia out of proportion to fever

›Tamponade physiology

›Pulsus paradoxus > 10 mmHg

›Elevated JVP with clear lungs

›Oxygenation and ventilation

›SpO2 target 94% to 98%

›Work of breathing from large effusion

›Cardiac tamponade recognition

›Beck triad

›Hypotension

›Distended neck veins

›Muffled heart sounds

›If tamponade with shock, emergent pericardiocentesis

›Echo guidance preferred

›IV fluid bolus as temporizing bridge

›Avoid aggressive diuresis or preload reduction

›Worsens forward flow in tamponade

›Maintain preload until drainage

›Key early branching

›Uncomplicated acute pericarditis

›No effusion or small effusion

›Hemodynamically stable

›Complicated pericarditis

›Large effusion > 2.0 cm

02History/hx67

Presentation pattern

›Core chest pain syndrome

›Sharp pleuritic retrosternal pain

›Worse supine

›Improved sitting up and leaning forward

›Radiation to trapezius ridge

›Virtually pathognomonic

›Reflects phrenic nerve involvement

›Onset and timing

›Often abrupt over hours

›Constant or intermittent course

›Associated symptoms

›Constitutional features

›Low-grade fever and malaise

›Fatigue

›Respiratory overlap

›Dyspnea

›Cough

›Prodrome

›Viral URI 1 to 3 weeks prior

›Recent gastroenteritis

Risk factors

›Personal risk factors

›Demographics

›Male sex

›Young to middle age

›Recent triggers

›Viral illness as most common trigger

03Physical Exam/exam52

Vitals and general

›Stability snapshot

›Temperature

›Low-grade fever common

›High fever > 38.5 C as red flag

›Heart rate

›Sinus tachycardia typical

›Irregular rhythm suggesting atrial fibrillation

›Blood pressure

›SBP < 90 mmHg as shock marker

›Pulsus paradoxus > 10 mmHg

›General appearance

›Positional comfort

›Leaning forward for relief

›Distress when supine

›Systemic illness signs

›Pallor or diaphoresis

›Toxic appearance with bacterial cause

Cardiac and hemodynamic exam

›Pericardial friction rub

›Acoustic character

›High-pitched scratchy quality

›Triphasic atrial systole, ventricular systole, early diastole

›Auscultation technique

›Diaphragm at left lower sternal border

›Patient leaning forward in end-expiration

›Limitations

›Present in under 30% of cases

04Differential Diagnosis/ddx43

Life threats and close mimics

›Immediate threats

›Acute coronary syndrome or STEMI

›ICD-10 I21.3 ST elevation MI

›Regional ST elevation with reciprocal changes

›Aortic dissection

›ICD-10 I71.00

›Tearing pain with pulse or BP differential

›Pulmonary embolism

›ICD-10 I26.99

›Pleuritic pain with right heart strain

›Cardiac mimics

›Myocarditis

›Troponin rise with LV dysfunction

›Concomitant myopericarditis in about 15%

›Cardiac tamponade

›ICD-10 I31.4

›Complication of pericarditis itself

›Early repolarization

›Concave ST elevation in young patients

›ST to T ratio < 0.25 in V6

›Non-cardiac mimics

›Pneumonia or pleuritis

›Fever with productive cough

›Focal lung findings

›Pneumothorax

›Sudden unilateral decreased breath sounds

›Hyperresonance

05Laboratory Tests/lt45

Inflammatory markers

›Inflammation panel

›C-reactive protein

›Elevated in about 78%

›Guides treatment response and NSAID taper

›Erythrocyte sedimentation rate

›Supports inflammatory phenotype

›Trends with disease activity

›Complete blood count with differential

›Neutrophilic leukocytosis supports inflammation

›Lymphopenia in some viral causes

Cardiac and organ function

›Myocardial markers

›Troponin

›Elevated in about 30%

›Elevation without LV dysfunction defines myopericarditis

›Not a negative prognostic marker in isolated pericarditis

›BNP or NT-proBNP

›Generally normal in isolated pericarditis

›Elevation suggests myocardial involvement or HF

›Metabolic panel

›Basic metabolic panel

›Baseline renal function before NSAIDs

›Exclude uremia as cause

›Glucose

›Baseline before corticosteroids

›Stress hyperglycemia marker

06Diagnostic Tests/dt86

Scoring Systems

›High-risk feature stratification

›Major poor-prognosis criteria

›Fever > 38 C

›Subacute onset

›Large effusion > 2.0 cm or tamponade

›Failure to respond to NSAIDs within 1 week

›Minor poor-prognosis criteria

›Myopericarditis

›Immunosuppression

›Trauma

›Oral anticoagulant therapy

›Interpretation

›Any major or minor feature favors admission

›Absence of all features supports outpatient care

›ECG staging system

›Four classic stages

›Stage I diffuse concave ST elevation with PR depression

›Stage II ST normalizes and T waves flatten

›Stage III diffuse T-wave inversions

›Stage IV ECG normalizes

›Diagnostic yield

›ECG changes in 25% to 60% of cases

›Spodick sign of downsloping TP segment

›Diagnostic criteria

›Requires 2 of 4 features

›Characteristic pleuritic chest pain

›Pericardial friction rub

07Disposition/dispo40

Level of care selection

›Admission indications

›High-risk clinical features

›Fever > 38 C

›Subacute insidious course

›Effusion and hemodynamics

›Large effusion > 2.0 cm or tamponade

›Hemodynamic instability

›Treatment and host factors

›Failure to respond to NSAIDs after 1 week

›Oral anticoagulant use with hemorrhagic effusion risk

›ICU indications

›Tamponade requiring intervention

›Pericardiocentesis with hemodynamic monitoring

›Vasoactive support

›Concomitant myocarditis with dysfunction

›LV dysfunction

›Ventricular arrhythmia

›Suspected purulent pericarditis

›Septic physiology

›Source control planning

Discharge criteria and follow up

›Outpatient criteria

›Low-risk profile

›No major or minor risk features

›Small or no effusion

›Treatment response

›Responsive to initial NSAID therapy

08Treatment/t77

Initial stabilization

›Resuscitation measures

›Standard supportive care

›IV access and continuous monitoring if unstable

›Supplemental oxygen to SpO2 target 94% to 98%

›Tamponade management

›Emergent pericardiocentesis for tamponade

›IV fluid bolus as temporizing measure

›If purulent pericarditis, surgical drainage and antibiotics

›Broad-spectrum coverage pending cultures

›Cardiothoracic surgery involvement

First-line pharmacotherapy

›NSAID therapy

›Ibuprofen regimen

›Ibuprofen 600 to 800 mg PO every 8 hours

›Total 1600 to 2400 mg per day

›Taper 200 to 400 mg every 2 to 4 weeks after symptom and CRP resolution

›Aspirin alternative

›Aspirin 650 to 1000 mg PO three times daily

›Preferred with concomitant coronary artery disease

›Taper after symptom resolution

›Gastroprotection

›Proton pump inhibitor with NSAID therapy

›Take NSAIDs with food

›Colchicine therapy

›Weight-based dosing

›Colchicine 0.5 mg twice daily if > 70 kg

›Colchicine 0.5 mg once daily if 70 kg or less

09Special Populations/sp39

Pregnancy

›Pregnancy considerations

›Medication safety by trimester

›NSAIDs acceptable before 20 weeks

›Avoid NSAIDs after 20 weeks due to ductal and renal risk

›Colchicine use

›Generally continued in familial Mediterranean fever

›Shared decision-making for pericarditis

›Corticosteroid role

›Low-dose prednisone often preferred later in pregnancy

›Monitor maternal glucose and blood pressure

›Imaging approach

›Echocardiography as first-line, no radiation

›CT only when benefits outweigh fetal risk

Geriatric

›Older adult features

›Atypical presentation

›Less prominent positional pain

›Higher proportion with effusion

›Etiology shift

›Higher malignancy and uremic causes

›Lower idiopathic proportion

›Medication risk

›NSAID caution with renal impairment and heart failure

›Colchicine dose reduction with renal impairment

›Disposition bias

›Lower threshold for admission

›Comorbidity decompensation risk

10Background/b44

Epidemiology

›Frequency and burden

›ED presentation

›About 4.4% of nonischemic chest pain in the ED

›More common in men aged 16 to 65

›Etiology distribution

›Idiopathic or viral in 80% to 90%

›TB leading cause in endemic regions

›Complication rates

›Recurrence in 15% to 30%

›Cardiac tamponade in under 3%

›Constrictive pericarditis in under 0.5%

Pathophysiology

›Mechanisms

›Pericardial inflammation

›Visceral and parietal layer irritation

›Friction rub from inflamed surfaces

›Effusion formation

›Exudative fluid accumulation

›Tamponade when intrapericardial pressure exceeds filling pressure

›Phenotypes

›Inflammatory in 80% to 90% with elevated CRP

›Noninflammatory in 10% to 20% often autoimmune-associated

›Myocardial involvement

›Concomitant myocarditis in about 15%

›Troponin elevation with possible LV dysfunction

Therapeutic Considerations

›Treatment strategy principles

11Patient Discharge Instructions/pdi21

copy discharge instructions

›Acute pericarditis home care

›Take all medications exactly as prescribed

›Do not stop colchicine early as it prevents recurrence

›Take anti-inflammatory medicine with food

›Rest and limit strenuous activity for at least 1 month

›Warning signs to return to ER

›Worsening chest pain not relieved by medication

›New or worsening shortness of breath

›Trouble breathing when lying flat

›Lightheadedness, fainting, or near-fainting

›Fever above 38 C

›New leg swelling

›Follow up

›Clinic follow up within 1 to 2 weeks

›Repeat blood test to guide medication taper

›Repeat heart ultrasound if fluid was present

›Activity and recovery tips

›Avoid vigorous exercise until cleared

›Keep heart rate under 100 during activity

›Avoid alcohol during recovery

›Most people recover within 1 to 2 weeks

12References/r12

Guidelines and key sources

›Guideline sources

›2025 ACC Expert Consensus on diagnosis and management of pericarditis

›2021 AHA ACC chest pain evaluation guideline

›AAFP rapid evidence review on acute pericarditis

›Landmark trials and reviews

›ICAP and CORP colchicine trials for recurrence prevention

›JAMA 2024 review on diagnosis, risk stratification, and treatment

›NEJM 2014 review of acute pericarditis

›Coding standards

›ICD-10 I30.9 acute pericarditis unspecified

›ICD-10 I31.4 cardiac tamponade

›SNOMED CT acute pericarditis disorder concept

Evidence & Review

Evidence & Review