1. same as pericardiditis - viral, idiopathic, neoplastic, autoimmune, Dressler's syndrome (s/p MI)
2. may be traumatic

• distant heart sounds (effusion)
• increased JVP
• systemic hypotension
• PERICARDIAL TAMPONADE

1. Beck's triad
2. pulsus paradoxus - drop > 10 of SBP w/ inspiration (pulses dissapear w/ inspiration)
3. Kussmaul's sign - increased JVP w/ inspiration

1. ECG: low voltage QRS complex, electric alternans
2. Echo: increased pericardial fluid + diastolic collapse of cardiac chambers (hemodynamic compromise)

• must be referred immediately to an ophthalmologist.

Start

• IV carbonic anhydrase inhibitor (ie acetazolamide)
• topical BB
• and
• osmotic diuresis (ie. mannitol

1. referred to ophthalmologist 
2. topical and/or systemic medications to decrease the IOP by decreasing aqueous production (BB, carbonic anhydrase inhibitors) 
3. and/or increasing outflow (prostaglandin-like meds, cholinergic agents, epiephrine components) 
4. alpha agonists (brimonidine) provide both mechanisms

cough

dyspnea of insidious onset

chest discomfort

erythema nodosum 

or

enlargement of parotid glands, lymph nodes, liver, or spleen

leukopenia

eosinophlia

elevated erythrocyte sedimentation rate

hypercalcemia

hypercalciuria

transbronchial biopsy of the lung or fine-needle node biopsy

biopsy shows noncaseating granulomas 

approximately 90% of cases are responsive to corticosteroids and can be controlled with modest maintenance doses

hypoxia 

other causes : acidosis and veno-cocclusive conditions

• dyspnea, angina-like retrosternal CP, weakness, fatigue, edema, ascites, cyanosis, & effort syncope

• narrow splitting and accentuation of the second heart sound 
• systolic ejection click

• CXR - enlarged pulmonary arteries
• EKG - RVH, atrial hypertrophy, RV strain
• Echo - estimating pulm arterial pressure but right heart catheterization offers more precise hemodynamic monitoring 

• chronic oral anticoagulants
• CCB to lower systemic arterial pressure
• prostacyclin (potent pulm. vasodilator)
• Heart-lung transplantation usually is needed

• thrombi in the systemic venous circulation or the right side of the heart
• from tumors that have invaded the venous circulation
• other sources

the deep veins of the lower extremities

others include:

• air emboli from central lines
•  amniotic fluid from active labor
• fat from long bone (femur fx)

1. hypercoagulable state
2. venous stasis
3. vascular intimal inflammation or injury

• PULMONARY EMBOLISM
• specific risks include: sx procedures (orthopaedic, pelvic, abdominal), cancer, oral contraceptives, and pregnancy

a PE

half will be asymptomatic

symptomatic PE is serious and potentially life threatening

• sudden onset of pleuritc CP
• dyspnea
• apprehension
• cough
• hemoptysis
• diaphoresis

• tachycardia
• tachypnea
• crackles
• accentuation of pulm component of 2nd heart sound
• low grade fever

• anticoagulation tx is initiated; heparin is anticoagulant of choice. LMWH or warfarin is continued after the acute phase
• a minimum of 3 months is advised
• Vena cava interruption (filter) is helpful in patients at high risk of recurrent who are unable to tolerate anticogulants
• Prevention is key! high risk patients: early ambulation, intermittent pneumatic compression stockings, low dose heparin and LMWH or a combo of mechanical and pharmacological measure

1. O2, isotonic fluids (avoid aggressive IV fluid tx w/ smaller amounts of fluid) 
2. inotropic suppor: drugs to increase myocardial contractility & CO - dobutamine (positive inotroe), epi(pos. inotrope & vasoconstrictor), amnirone.  intraortic balloon pump
3. treat underlying cause: ie. MI: early angioplasty or thrombolytic tx 

• O2, isotonic fluids, inotropic support : dobutamine, ep, intra aortic abloon pump
• treat underlying cause

1. PE : heparin, thrombolytic tx +- embolectomy
2. pericardial tamponade - pericardiocentesis
3. tension PTX - needle decompression
4. proximal dissections usually require sx

• broad spectrum IV abx: early tx. Zosyn + Ceftriaxone or imipenem

1. gent for pseudomonas
2. vanc for MRSA
3. clinda or metronidazole for intraabdominal
4. Ceftriaxone in asplenic pts to cover N. meningitides & H. flu

• IV fluid resuscitation: isotonic crystalloids (NS, LR)
• vasopressors: if no response to 2-3 L of IV fluids with goal of MAP > 60 mmHg. +- 100 mg IV hydrocortisone

• epi 1st line (0.3 mg IM of 1:1000 repeat q5-10m)
• IV CV collapse give 1 mgIV of 1:10,000
• airway management
• antihistamines (diphenhydramine 25-50mgIV blocks H1, rantidine IV blocks H2)
• IV fluids
• observe pts for 4-6 hrs b/c up to 20% have biphasic phenomenon (return of sx 3-4 hrs after inital rxn)

fluids

pressors

+- steroids

1. Airway
2. Breating: mechanical vent & sedation decrease work of breathing
3. Circulation: isotonic crystalloids (NS, LR) 
4. Deliver of O2: monitor lactate levels
5. Endpoint of resuscitation: urine output: 0.5 mg/kg/hr, CVP 8012. MAP 65-90, Central venous o2 >70%

• ABCDE's, insert 2 large bore IV's or central line
• volume resuscitation: crystalloids often given 3-4 L 
• +- packed RBC transfusion: if hemorrhage (O-neg or cross matched)
• prevention of hypothermia, treat any coagulopathies