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Immediate stabilization
Unstable presentations
Hypotension
Escalate to resuscitation bay for shock physiology
If pulsus paradoxus with shock, pericardial tamponade pathway
Severe respiratory distress
Oxygen titrated to clinical targets
If impending respiratory failure, airway plan with tamponade precautions
Altered mental status
If persistent, shock pathway and alternate diagnosis pathway
Monitoring and access
Cardiac monitor
Continuous rhythm observation for atrial arrhythmia
12 lead ECG
If STEMI criteria, ACS pathway with pericarditis mimic check
IV access
Two large bore peripheral lines for unstable physiology
Point of care ultrasound
If hypotension, pericardial effusion and tamponade signs
Time critical exclusions
Acute coronary syndrome
If persistent pain or ischemic ECG features, ACS evaluation pathway
Pulmonary embolism
If hypoxia or pleuritic pain with risk factors, PE pathway
Aortic dissection
If tearing pain or pulse deficit, aortic syndrome pathway
Esophageal rupture
If severe vomiting with chest pain, mediastinitis pathway
Key concepts
Syndrome framing
Acute pericarditis
Inflammatory chest pain syndrome with pericardial irritation
Myopericarditis
Pericarditis with myocardial injury markers
Pericardial effusion
Fluid without mandatory inflammation
Cardiac tamponade
Hemodynamic compromise from elevated intrapericardial pressure
Diagnostic criteria
Acute pericarditis requires at least 2 of 4 criteria
Typical pericardial chest pain
Pericardial friction rub
New widespread ST elevation or PR depression
New or worsening pericardial effusion
PITFALLS
Common misses
STEMI misdiagnosis
Regional ST elevation with reciprocal changes favors STEMI over pericarditis
Tamponade without classic triad
Normotension possible in subacute effusions
Myocarditis overlap
Troponin elevation with LV dysfunction changes disposition and activity guidance
Anticoagulation or trauma history
Hemopericardium risk with small effusions still clinically important
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.