eMedicine Specialties > Emergency Medicine > Cardiovascular

Pericarditis and Cardiac Tamponade: Treatment & Medication

Author: Verena T Valley, MD, Associate Professor, Director of Ultrasound, Department of Emergency Medicine, University of Mississippi School of Medicine; Consulting Staff, Department of Emergency Medicine, Singing River Hospital System, Singing River Hospital, and Ocean Springs Hospital
Coauthor(s): Christopher A Fly, MD, Assistant Professor, Department of Emergency Medicine, Medical College of Georgia
Contributor Information and Disclosures

Updated: May 12, 2008

Treatment

Prehospital Care

Patients with chest pain, regardless of etiology, should routinely be treated with oxygen and cardiac monitor.

  • Pericarditis - Routine care as for patients with acute cardiac conditions
  • Cardiac tamponade
    • The initial prehospital care is the same as for any major trauma. The diagnosis may be suspected based on the location of penetrating wounds.
    • Consider the possibility of a tension pneumothorax.

Emergency Department Care

The emergency care of the patient centers on prompt diagnosis and treatment of potentially life-threatening entities.

  • Pericarditis
    • Ideally, echocardiography should be readily available to determine the presence or absence of a pericardial effusion.
    • If no pericardial effusion is noted, stable patients with presumptive viral pericarditis may be discharged with appropriate instructions and follow-up care.
    • If a small- to medium-sized effusion is present, the patient should be admitted for observation and serial echocardiography. If a large effusion is present, the stable patient may undergo an urgent pericardiocentesis or placement of a pericardial window.
  • Cardiac tamponade
    • Treatment depends on stability. Patients who are unstable require immediate treatment of the increase in pericardial pressure with pericardiocentesis. Removing as little as 30-50 mL may produce dramatic hemodynamic improvement.
    • Patients may have subacute tamponade (intermittently decompressing) and may benefit from decompression in the operating room with cardiothoracic care available to treat cardiac injuries.

Consultations

  • Nontraumatic pericardial disease - Internal medicine or cardiology specialists
  • Traumatic pericardial injury - Trauma or cardiothoracic surgery specialists

Medication

Patients with idiopathic or viral pericarditis should be treated symptomatically. Several small studies have noted successful use of colchicine to prevent recurrence of acute pericarditis after failure of conventional treatment, especially in idiopathic cases.3,4 One report found marked improvement following corticosteroid therapy in a patient with refractory uremic pleuropericarditis.5

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Because pericarditis is primarily due to inflammation, anti-inflammatory medications are considered the drugs of choice.


Ibuprofen (Motrin, Advil, Ibuprin)

Usually DOC for mild to moderate pain, if no contraindications are noted.
Inhibits inflammatory reactions and pain, probably by decreasing the activity of the enzyme cyclooxygenase, which results in prostaglandin synthesis.

Adult

400-800 mg PO q4-8h

Pediatric

<6 months: Not established
6 months to 12 years: 10-70 mg/kg/d PO divided tid/qid; start at the lower end of dosing range and titrate upward to a maximum of 2.4 g/d
>12 years: Administer as in adults

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy


Indomethacin (Indocin)

Often considered the first choice. Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis.

Adult

25-50 mg PO q6h

Pediatric

1-2 mg/kg/d PO divided bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur, (discontinue if there is persistent leukopenia, granulocytopenia, or thrombocytopenia)


Ketoprofen (Oruvail, Orudis, Actron)

For relief of mild to moderate pain and inflammation. Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease. Doses of more than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient response.

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy


Naproxen (Anaprox, Naprelan, Naprosyn)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

Adult

500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.


Prednisone (Deltasone, Meticorten, Meticorten, Sterapred)

May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.

Adult

5-60 mg/d PO qd or divided bid/qid

Pediatric

4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid

Coadministration with estrogens may decrease clearance; concurrent use with digoxin, may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or tubercular skin infections; GI disease

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

More on Pericarditis and Cardiac Tamponade

Overview: Pericarditis and Cardiac Tamponade
Differential Diagnoses & Workup: Pericarditis and Cardiac Tamponade
Treatment & Medication: Pericarditis and Cardiac Tamponade
Follow-up: Pericarditis and Cardiac Tamponade
Multimedia: Pericarditis and Cardiac Tamponade
References
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References

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Further Reading

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Keywords

pericardium, pericardial complex, acute pericardial tamponade, pericardial effusion, malignancy, tuberculous pericarditis, precordial chest pain, retrosternal chest pain, end-stage renal disease, ESRD, traumatic tamponade, decompressing tamponade, pericardial friction rub, premature atrial contractions, premature ventricular contractions, cardiac arrhythmias, tachypnea, dyspnea, myocarditis, Ewart sign, hepatomegaly, ascites, Beck triad, jugular venous distention, hypotension, muffled heart sounds, pulsus paradoxus, cyanosis, serous pericarditis, rheumatoid arthritis, RA, systemic lupus erythematosus, SLE, fibrous pericarditis, serofibrinous pericarditis, acute myocardial infarction, AMI, Dressler syndrome, uremia, radiation, suppurative pericarditis, purulent pericarditis, cardiotomy, constrictive pericarditis, hemorrhagic pericarditis, bleeding diathesis, caseous pericarditis, adhesive mediastinopericarditis, concretio cordis, malignant pericarditis, penetrating cardiac injuries, hemopericardium, pericardial hematoma, pacemaker insertion, cardiac catheterization, sternal bone marrow biopsies, pericardiocentesis, dermatopolymyositis

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Contributor Information and Disclosures

Author

Verena T Valley, MD, Associate Professor, Director of Ultrasound, Department of Emergency Medicine, University of Mississippi School of Medicine; Consulting Staff, Department of Emergency Medicine, Singing River Hospital System, Singing River Hospital, and Ocean Springs Hospital
Verena T Valley, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher A Fly, MD, Assistant Professor, Department of Emergency Medicine, Medical College of Georgia
Christopher A Fly, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

David A Peak, MD, Assistant Residency Director of Harvard Affiliated Emergency Medicine Residency, Attending Physician, Massachusetts General Hospital; Consulting Staff, Department of Hyperbaric Medicine, Massachusetts Eye and Ear Infirmary
David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA
Eric Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Charles V Pollack, Jr, MD, MA, FACEP, Professor, Department of Emergency Medicine, University of Pennsylvania College of Medicine; Chairman, Department of Emergency Medicine, Pennsylvania Hospital
Charles V Pollack, Jr, MD, MA, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: sanofi-aventis Honoraria Consulting; sanofi-aventis Honoraria Speaking and teaching; Schering-Polugh Honoraria Consulting; Schering-Plough Honoraria Speaking and teaching; The Medicines Company Honoraria Consulting; GlaxoSmithKline Grant/research funds Other

 
 
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