Pericarditis Symptoms And Signs


Categories: Uncategorized
Sources: Disturbances Of The Heart

If there is pain or much aching in the cardiac region, it tends to

disappear with the exudate, if such is to occur, in the same way as

does the pain of pleurisy. If there is much exudate, the pressure on

the heart of course increases, the cardiac dulness enlarges, dyspnea

occurs and even perhaps later cyanosis. As the exudate accumulates,

the patient must lie higher and higher in order that the fluid may

gravitate to the lowest part of the sac and give the heart the

greatest ability to work. Reflex pain may occur from disturbances of

the pneumogastric nerve, or from the weight and pressure of the

enlarged and heavy pericardium. Reflex vomiting may be a troublesome

and distressing symptom.



Acute pericarditis occurring in rheumatism, in acute infections, and

from simple injuries tends to recovery. In dry pericarditis with

serious adhesions, or if adhesions occur as a sequence of acute

pericarditis, the future prognosis is bad, as myocarditis may

develop and sudden death or acute dilatation may occur. As stated

above, if pericarditis develops during the progress of chronic

disease, such as interstitial nephritis, or during sepsis, or from

abscesses or growths in the region of the pericardium, the prognosis

is bad.





TREATMENT OF ACUTE PERICARDITIS



In acute pericarditis, absolute mental as well as physical rest is

essential. Even if the patient does not appear to be seriously ill

and has not much fever, he should not be allowed to have visitors,

to discuss business matters, or to carry on any conversation,

however little exciting. Anything which increases the heart beat

increases the irritation of the inflamed surfaces of the

pericardium. He should not be allowed to sit up, either to eat or to

attend to the calls of Nature. These rules are imperative, and when

they are followed the pain is less, the heart beats less rapidly, is

less hampered by pressure from whatever exudate may be present, and

the adhesions which are liable to form will be less in amount and

less serious for the future work of the heart.



The treatment, of course, depends largely on the cause of the

pericarditis, as, if the cause is one of those just enumerated in

which the prognosis is dire, any treatment directed toward the

pericardial inflammation is almost useless. The periearditis under

these conditions will be more or less benefited, if at all affected,

by the treatment directed toward the cause.



The indications for treatment in all other instances are:



1. To attempt to abort the inflammation.



2. To stop the pain.



3. To limit, if possible, the amount of exudate, and to diminish the

exudate already present.



4. To diminish the rapidity of the heart and to strengthen it.



1. Abortive Treatment.--For many years bloodletting was considered

of the greatest importance in the early treatment of this disease;

but owing to the fact that, except from traumatism, pericarditis

rarely occurs except as a sequela of acute disease after the patient

has been sick along time, or as a terminal condition in a patient

who has long been chronically diseased and therefore has already

lost more or less strength, venesection has been nearly abandoned.

Leeches may be used over the region of the pericardium, and cups are

sometimes used. Dry cupping is more frequently used. These measures

sometimes seem to reduce the inflammation, and certainly often

relieve pain, but the most valuable local treatment is cold, which

may be applied either in the form of an ice bag or by a small coil

through which ice water is caused to flow by siphonage. Cold may be

applied more or less continuously, depending on the sensations of

the patient. The bag or ice cap must not be overfilled and must not

be heavy, as the patient often cannot stand pressure over the

pericardium. Sometimes the relief from pain and the diminution of

the number of the heart beats is marked, and for this reason alone

the cardiac inflammation may be inhibited. If cold applications are

not tolerated by the patient (and they often are not in children)

warm applications may be used, such as an electric pad or cloths

wrung out of hot water and covered with oiled silk, and the pain

will often be relieved thus. While hot applications would not tend

to abort the inflammation, they probably do not tend to promote it.



A diminished diet, of small amount at a time, and such purging as

the patient's strength will allow are essential in attempting to

hasten recovery.



Just what can be done locally or generally to combat the

inflammation actively must depend on the cause. When the

inflammation occurs as a complication of acute rheumatism, it has

been suggested that salicylates, which arc not inhibiting rheumatism

and may be depressant to the heart, should be stopped if they are

being administered; but if the salicylates are apparently improving

the inflammation in the joints, pericarditis would not

contraindicate their continued use. Except in large doses,

salicylates probably do not depress the heart. In pericarditis it is

perhaps well always to administer an alkali in some form unless

otherwise contraindicated, whether or not the cause is rheumatism. A

diminished alkalinity of the blood would always increase the

likelihood of an augmented amount of pericardial or endocardial

inflammation. The blood must be kept strongly alkaline. It is

possible that one of the reasons why pericarditis or endocarditis

occurs so frequently in serious prolonged fevers is that the patient

has not eaten enough cereals or other carbohydrates, and the system

has become more or less endangered by acidosis. Carbohydrate

starvation is inexcusable with our present understanding of the

danger from acideinia, and even from a diminished amount of alkalies

in the blood.



The cause of pericarditis being so varied, any anti-toxin treatment

or any vaccine treatment could be indicated only if the cause of the

inflammation rendered the serum or vaccine advisable.



2. Stopping the Pain.--Nowhere else in the body should pain be so

speedily combated as when it occurs in the region of the heart.

Morphin, with or without atropin, as deemed best, should be

administered hypodermically in the amount and with the frequency

necessary to stop the pain and quiet the restlessness. As stated

above, the frequent need for morphin may be prevented by use of the

ice bag. Morphin might even be considered an abortive treatment, as

nothing tends so much to inhibit this inflammation as the quietude

of the heart caused by the absence of pain, the production of sleep

and the prevention of restlessness, muscle twitching and muscle

movements. The more quiet the patient is, the more quiet is the

heart.



If for any reason morphin is contraindicated, and if pain is not a

symptom, the patient's nerves may be quieted and rest may be given

by sodium bromid, or by veronal-sodium, the dose of the former being

2 gm. (30 grains) two or three times in twenty-four hours, according

to its action and the necessity for it, and the dose of the latter

0.2 gm. (3 grains) once in six hours, if deemed necessary.



Especially if there are cerebral symptoms, as typically presented in

cerebrospinal meningitis, and especially if the arterial tension is

low, the subcutaneous administration of an aseptic ergot will quiet

the central nervous system, increase the blood pressure, quiet the

heart, and prolong the action of a single dose of morphin. It is the

best plan to administer ergot deep into the muscles, with the

deltoid as the place of choice. If the skin is properly cleansed,

the syringe clean and the preparation of the drug aseptic, no

inflammation or abscess will ever occur. If there is any painful

swelling, a wet alcohol dressing to the part will soon relieve it.

The frequence with which ergot should be so administered depends on

the results and the indications. Once in twelve hours for several

doses is generally the best method for its use.



3. The Exudate.--When a fluid exudate into the pericardium has

occurred from inflammation that is, when it is not an exudate from

disturbed kidneys or circulation--it will continue to increase to

some extent in spite of any treatment. Just how much this exudate

may be prevented by the use of small blisters over or around the

heart, and just how much watery stools and diuresis may prevent the

advance of the exudate is difficult to determine. Small blisters,

properly applied, have many times seemed to be the determining

factor in stopping the increase in the fluid, or to have been the

starting cause of the resorption of the exudate.



The amount of purging that should be caused by saline cathartics

such as sodium sulphate (Glauber salt), potassium and sodium

tartrate (Rochelle salt), or the official compound jalap powder

cannot be declared dogmatically. Saline purging should be governed

by the character of the circulation. If the heart is strong, the

pulse not weak, and the blood pressure good, nothing is more

valuable in this condition. Portal depletion is of great advantage,

especially if the amount of liquid ingested is kept as low as

possible, so that the blood vessels may become thirsty and thus tend

to absorb an exudate wherever they find it. Much harm has been done,

however, and death has been caused by saline purgatives in

endeavoring to relieve edemas from a failing heart or to prevent a

uremia from kidney inflammation. The depression following such

purging is often serious. If the circulation is weak, dependence

should be placed on purgation by some of the simple vegetable

cathartics or a small dose of calomel. While it is advisable to give

a saline in concentrated solution, it should not be so strong as to

cause vomiting. With our better understanding of magnesium

absorption and the depressant effect of magnesium on the nervous

system, magnesium salts should not be used in serious conditions.



Diuretics often do not act well when most needed. The simplest

diuretic is potassium citrate, given in wintergreen or peppermint

water, in doses of 2 gm. (30 grains), three or four tunes in twenty-

four hours. One or more of the vegetable, nonirritant diuretics may

be tried if preferred. If the sickness preceding the pericarditis

was not a long fever, and the heart muscle is considered in good

condition, digitalis in small doses may be the best possible

diuretic. Incidentally it will slow the heart, if there is not much

elevation of temperature, and will give some cardiac rest.



Although the patient's diet should be limited in bulk, and

especially in amount of liquids, good nutrition should soon be

given. Systemic weakness certainly tends to increase the exudate;

systemic strength aids in absorption of the exudate.



Iron is early indicated, and nothing is better than 5 drops of the

tincture of chlorid of iron in a little lemonade or orangeade,

administered once in eight hours.



If the exudate tends to decrease, it perhaps may be hastened by the

local application of tincture of iodin over the cardiac region. Also

the administration of small doses of an iodid, as 0.3 gm. (5 grains)

of sodium iodid, given in plenty of water three times a day, is

useful. An iodid circulating in the blood seems to aid absorption.

It has long been believed that iodin in the blood tends to promote

absorption of thickened, left-over material from exudates, and to

prevent the formation of strong fibrous adhesions. Until our

knowledge is more exact in this matter, it is advisable to use iodid

as suggested. If the above-named dose is not tolerated, less should

be given.



If in spite of all the therapeutic measures suggested, the fluid

increases and the pericardium becomes more distended and the heart's

action more labored, paracentesis must be done. The point at which

the aspirating needle should be inserted into the pericardium

depends somewhat on the conditions in each individual case. It is

often best to insert an exploratory needle first. This will

determine the fluidity and character of the exudate. If pus is

found, a more radical surgical procedure than simple paracentesis

must be done immediately. The point of puncture for aspiration most

frequently chosen is in the fourth or fifth intercostal space, about

an inch to the left of the sternal margin. Paracentesis is also

often done in the region of the normal apex beat. The position of

the patient is determined by his dyspnea; he should lie in the

position most comfortable for him. The fluid should be withdrawn

slowly and the pulse carefully watched. The withdrawal of a small

amount of fluid may later seem to be the starting cause of

resorption of the rest of the fluid. On the other hand, it may often

be not of more value than the simple removal of the immediate

pressure, the fluid may again accumulate, and more radical surgery

must be performed.



4. To Strengthen the Heart.--Most of the methods of meeting this

indication have already been stated, namely, absolute rest; absolute

quiet; the use of the bed pan; any movement that must be made should

be deliberate; the nurse and other attendants must be quiet;

necessary conversation must be brief, and every method must be used

to quiet and prevent the heart's action from becoming rapid. The

food taken should be small in amount and nonstimulating; that is, no

tea or coffee should be given, and nothing too hot or too cold.

Movements of the bowels should be caused with the least possible

general disturbance. If the patient does not sleep, he must be made

to sleep. The whole body and the nervous system must have periods of

rest. If the heart is very weak, small closes of morphin may be

used. If the heart is not weak, bromids or chloral may be given. If

the blood pressure is high, such hypnotics will lower it, or if the

heart is strong and the condition does not contraindicate it,

aconite may be used in small doses, for a day or two, unless the

fever is high and it seems advisable to use one of the coal-tar

antipyretics, which reduce the blood tension and the heart activity.



As stated above, pain must not be allowed. Sometimes, when the heart

has not been injured by prolonged fever, digitalis in small doses

may slow the heart and act for good.



Convalescence.--The convalescence should be prolonged as in any

other cardiac inflammation. The patient should be given more and

more nourishing food, and the iron tonic may be changed to a capsule

containing 0.05 gm. of quinin and 0.05 gm. of reduced iron, three

times a day.



It is a question as to when patients convalescent from pericarditis

should be permitted exercise. It has been thought that gentle

movements and possibly exercise, sooner than theoretically

justified, might cause the heart to beat a little more actively and

possibly prevent the formation of tight adhesions between the two

layers of the pericardium. Whether such activity of the heart will

prevent adhesions is something that has not been determined.



The small doses of sodium iodid, perhaps 0.2 gm. (3 grains) two or

three times a day, should be continued for some time. Iodid in this

dosage does no harm and may do a great deal of good.





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