Pericarditis for EMS – A Short and Sweet Case Review

“Man it’s hot!” you think to yourself while cleaning the back of your rig in the hospital ambulance bay. Those glass garage doors they put on here might make the garage look pretty, but they sure heat the place up in the summer time. You convince yourself that it was nice of them to install a sauna for the EMS crews and let the thought sustain you as you mop the floor of the truck. You and your partner have been running steady since you came on shift this morning, and the noontime sun is really blazing down out there. As the tones come across your radio and the dispatcher calls your unit, you realize that you’re not getting a break anytime soon.

Your partner comes out from the report room as you check the address on the map book. You’ve been called for the 47yo male patient complaining of chest pain. It’s not too far away and you arrive within a few minutes of the call. The patient’s wife lets you in to the house.

“He’s been sick in bed all day, really sick” she tells you as she leads you inside to the back bedroom of the house. “He’s been running a fever and having trouble breathing. I told him I was going to call you when he started telling me that his chest hurt.”

You find the patient sitting on the side of his bed leaning slightly forward and crossing his arms across his chest. His skin is flushed and warm to the touch. He’s breathing slowly and carefully, wincing slightly as he finishes every inhalation. You introduce yourself to the patient and ask him how he’s doing. He answers that his chest is killing him and that it’s been becoming progressively more painful to breathe. He denies feeling short of breath but states that it’s just too painful to get enough air in. He indicates with his hand that the pain is sub-sternal, and that it radiates to the bottom part of his left shoulder blade. He describes the pain as intense, “sharp and raw” and constant. He says that it’s worse when he lies down and when he moves.

Your partner checks the patient’s vital signs while you continue your assessment. You notice what you think may be a little bit of jugular venous distension when you look down at him but it’s hard to see in the light. His lung sounds are clear, His abdomen is soft and non-tender, and His recent history includes a slight fever and chills with progressive upper respiratory illness over the last two days. He adds that he’s been sick since he came home from his dentist’s office after having a cavity filled the other day and he’s wondering if the numbing medicine the dentist gave him had anything to do with it. Your partner tells you that his vital signs are: Pulse 112 and slightly irregular, BP 106/74, respiratory rate 18 with a pulse-ox of 98% on room air. Your partner said that something seemed strange when he listened for the patient’s blood pressure and he had to check it a few times. He says it was almost like the systolic pressure disappeared when the patient took a breath in.

Your partner places him on 4-litres of oxygen via nasal cannula as you strap the patient on the cot. He seems very uncomfortable when you try to lay him down and asks to be sat almost completely upright. You wheel him out of the house and put him in the rig. You decide to place the patient on the monitor, both the 5 lead and to acquire a 12-lead although you’re pretty sure that the patient’s complaint isn’t cardiac in nature. Your partner starts an IV with Normal Saline and you decide to transport the patient to his hospital of choice. You choose to follow the chest pain protocol just to be safe, and administer 4 baby aspirin and one nitro-tab sublingually. Then you look at the 12-lead and are horrified to see all of the changes. The patient has flipped T-waves and ST-segment changes in nearly every lead. This just got serious, and you ask your partner to flip on the lights and sirens as you transmit the 12-lead to the ER.

So what do you think this is?

We all know that not all chest pain is a heart attack and that many conditions that can lead to a patient feeling pain in their chest. This patient describes his pain as increasing with motion and respiration and as feeling “sharp” and “Raw” with radiation to his back under his scapula and states that the pain is relieved by sitting up and leaning forward. As any chest pain can be a symptom of a myocardial infarction or pulmonary embolism, it’s important to look at the total picture and try to rule out immediately life threatening conditions as best as possible. The medic in this fictional case followed protocols and “treated for the worst while hoping for the best” but even he was surprised to see the changes on the 12-lead.

The heart is contained in a tough, fibrous sac called the “Pericardium” which encases and protects the heart inside the chest. This sac positions the heart properly within the chest and keeps it from rubbing directly against any other structures within the thoracic cavity as it moves. Usually, the sac contains a small amount of fluid for lubrication. When the sac becomes inflamed, it is called “pericarditis”. This condition causes pain and other symptoms as described above, which include:

  • Diffuse pleuritic chest pain that tends to lessen with sitting upright and leaning forward but increases with breathing and lying flat. The pain is worsened by movement, but not necessarily by exertion. It does not decrease with administration of nitroglycerine.
  • The patient may present with a fever, or a cough. Usually the patient has the pain for hours or days before presenting for care.
  • The presence of diffuse EKG changes is usually associated with pericarditis, showing non-specific T-wave inversions and ST segment changes in multiple leads as shown on a 12-lead EKG. This is caused by the inflammation of the pericardium and the vasculature of the heart rather than a blockage in the arteries. However, occasionally a coronary artery can spasm and cause classic MI symptoms.

Pericarditis has many causes, including a bacterial or viral infection, an autoimmune response, or inflammation following a heart attack. While there may be a possible link between the condition and dental procedures, research has not yet discovered a direct link. However, some dentists prefer to place their patients on prophylactic antibiotics prior to an invasive procedure to help prevent infective pericarditis and/or endocarditis, which is a rare but serious infection within the inner chambers of the heart.

Field treatment for pericarditis includes judicious use of the system’s chest pain protocols. Place the patient on oxygen and administer aspirin and nitroglycerine as per protocol. Pain may be relieved with opiates but is not generally reduced with nitroglycerine. Acquire and transmit a 12-lead EKG early in the treatment so that the patient can go to an appropriate destination for care.

  • emtdan

    Very interesting case, thank you. What is the appropriate destination of care? Would this patient likely be taken. To the cath lab, or managed medically? What are the hospital assessments and treatments? Thanks1

    • ParamedicNurse

      EMTDan: This patient would be managed medically for now but would be
      served best being transported to a major heart hospital. By that, I
      mean a hospital which has capability to do invasive cardiac procedures,
      including cardiac surgery, if need be.

      Once in ED the patient would have a repeat ECG done, labs drawn
      including blood cultures and cardiac enzymes, chest X-ray which would
      presumably show an enlarged cardiac silhouette and probably an
      echo-cardiogram. The patient would be admitted and treated with IV
      antibiotics and anti-inflammatory medications. You may also expect
      medications to decrease cardiac pre-load and/or after-load depending on
      the patient’s presentation and cardiac co-morbidities while the heart is
      recovering.

  • oliemt

    Why is oxygen and IV fluids given?

    • Foxfiredawg

      O2 given as precaution, tidal volume is slightly diminished and respiratory rate is WNL. It was given at 4 LPM via NC. Fluids were given due to lower than desired BP and also as a precaution, in case the patient deteriorated and needed more fluids or drugs.

  • Jacques Basson

    Thanx a lot. Some interesting reading and updating myself also. One question,why do you(in this cenario) use a nasal prong instead of a 60% rebreather/polymask. Here in South Africa we don’t use nasal prongs on Ambulances at all. Only 40 and 60% masks. Looking forward to next cenario!!!!

    • BH

      Technically with an SPO2 of over 94%, American Heart Association guidelines say the patient doesn’t need any oxygen, but is usually given as a comfort measure anyway. And when you’re giving it “just because” they certainly don’t need a mask- a couple of liters will do just fine. If they DO need a mask, chances are they usually need more than 40-60%.

  • Jreyesjr1338

    Had a 10 year old boy with chest pain, mom stated he had pericarditis and as a new medic wasn’t familiar with it so I aired on the side of caution and treated as ACS and ER Docs were satisfied ! Very good info to share..

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  • Pjmartinez07

    Very good information, for all our EMS staff we are using now 12 lead in all state’s units tthanks for all that info.

  • Pingback: Pediatric Cardiac Complacency - A Case Study for EMS | Life Under the Lights

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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  • Comments
    Ckemtp
    I Got Attacked – A Paramedic Speaks About Public Trust
    I somewhat agree, though I assure you I didn't set out to waste your time. I probably should have broken this down into two separate points as the second point was the one I most wanted to emphasize. My bad on this one, I'll do better next time. Thanks for the feedback. If you'd like,…
    2014-12-16 20:25:00
    hawk4080
    I Got Attacked – A Paramedic Speaks About Public Trust
    Wow. That was a total waste to read.
    2014-12-16 19:20:00
    retired ems medic
    I Got Attacked – A Paramedic Speaks About Public Trust
    The radios should have had a trouble button to eliminate the need to key the Mike and talk. Maybe the dispatchers need to be rotated out to the streets to get out of the mode of just getting the calls out and only half listening to the radio.
    2014-12-16 14:50:00
    HybridMedic
    I Got Attacked – A Paramedic Speaks About Public Trust
    We use "Signal C" as a code to relay a crew in distress. Takes a second for the dispatchers to confirm it, but it sends the nearest engine, battalion chief, fire investigator (who are sworn LEO's) and makes an officer in distress call to Memphis Police. The arrival of all those resources is quite... Dramatic.
    2014-12-15 14:29:00
    exmedic
    Welcome to the Club
    Not me anymore
    2014-12-15 09:17:00

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