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D.H.
Setting
HPI
congestion
D.H.
Vomiting
Diarrhea
Loose, BID
No mucous, no blood
Watery
D.H.
Now with decreased activity, progressive shortness
of breath and difficulty breathing
Mid- to upper-back pain with deep inspiration
Pleuritic chest pain
Feels as though heart is racing at times
PMH
Immunizations UTD
D.H.
FHx
ROS
Vital
signs
At this point
We
Jen
History Clarification
Any travel?
Any
trauma?
History
of rash?
Difficulty
What
breathing?
Jen
Most Important PE Findings
Overall Appearance
Cardiovascular (esp M/R/G)
Pulmonary
Abdomen
GU Examination
Additionally:
Hydration status?
Edema?
Rash?
Nathan
History Clarification
Does position make breathing worse?
How
did he sleep?
What
Why
is his weight?
10
Nathan
Temp source?
Skin/eyes (icterus?)
HEENT (big erythematous tonsils?)
Abdomen (HSM?)
Edema of extremities?
Cardiac (MRG?)
Pulmonary (Edema?)
11
What we asked
Differential
Diagnosis
Top Diagnosis
What labs?
What imaging?
What would you do in the meantime?
12
Labs
13
D.H.s Labs
14
15
16
17
18
D.H.s Course in ED
Initially
19
D.H.s Course in ED
Signed
20
Additional Labs in ED
21
Echo
Dilated
cardiomyopathy
Severely dilated LV with global severely depressed left
ventricular function (left ventricular ejection fraction 1015%)
Severely
22
to CICU
LVAD placement 1/29/15 (10 days post
arrival)
Underwent
23
Arrhythmogenic
Anthracycline
Noncardiac causes
Drug/toxin exposure
Anomalous left coronary artery arising off the pulmonary artery (ALCAPA)
Sepsis
Renal failure
Hsu DT, Pearson GD. Heart failure in children: part I: history, etiology, and pathophysiology. Circ Heart Fail 2009; 2:65.
24
Cardiomyopathy
Most
Myocarditis
Viral inflammation of heart muscle leading to
either complete recovery of LV function or dilated
cardiomyopathy
At least of all cases of DCM are caused by
myocarditis
Lipshultz SE, Sleeper LA, Towbin JA, et al. The incidence of pediatric cardiomyopathy in two regions in the United States. N Eng J Med 2003;
348:1647.
25
Classification of
Myocarditis
Rose, N.R., Myocarditis: infection versus autoimmunity. J Clin Immunol, 2009. 29(6): p. 730-7.
26
Presentations of Mycocarditis
Freedman, S.B., et al., Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation, in Pediatrics2007: United States. p.
1278-85.
27
Kindermann, I., et al., Update on myocarditis, in J Am Coll Cardiol2012, 2012 American College of Cardiology Foundation. Published by Elsevier Inc: United States. p. 779-
28
Labs (n=31)
Freedman, S.B., et al., Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation, in Pediatrics2007: United States. p.
29
Diagnosis
Mahrholdt, H., et al.,Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology, inCirculation2004: United
States. p. 1250-8.
30
Management Goals
Cardiovascular
Inotropic support
Afterload reduction
Arrhythmia management
Tissue oxygenation
Respiratory
Mechanical ventilation
FEN
Bolusesvsdiuretic therapy
31
Inotropic Support
Dopamine:
vasodilation
Dobutamine:1&SVR, increased oxygen
supply to the coronaries, significantHR is a SE
Epinephrine:1& 1dose
dependent,arrhythmogenic
Milrinone: PDE inhibitor that improves
contractility, diastolic function and afterload
reduction
Start thinking about mechanical support
Uhl, T.L.,Viral myocarditis in children, inCritCare Nurse2008: United States. p. 42-63; quiz 64.
32
Arrhythmia management
Ventricularectopy,tachycardias, heart block
If occur, will cause further deterioration of
ventricular function
Adenosine: slows conduction through AV
node for SVT
Amiodarone: inhibits adrenergic stimulation
Lidocaine: suppresses automaticity of the
conduction system
Heart block for >2 weeks: pacemaker
Uhl, T.L.,Viral myocarditis in children, inCritCare Nurse2008: United States. p. 42-63; quiz 64.
33
Respiratory Management
Positive
Uhl, T.L.,Viral myocarditis in children, inCritCare Nurse2008: United States. p. 42-63; quiz 64.
34
FEN Management
Preserve
Uhl, T.L.,Viral myocarditis in children, inCritCare Nurse2008: United States. p. 42-63; quiz 64.
35
Additional Management
Options
ECMO
Morales, D.L., et al., Bridging children of all sizes to cardiac transplantation: the initial multicenter North American experience with the Berlin Heart EXCOR ventricular assist
device, in J Heart Lung Transplant2011, 2011 International Society for Heart and Lung Transplantation. Published by Elsevier Inc: United States. p. 1-8.
36
Additional Management
Options
Jansen, P., et al., In vitro haemocompatibility of a novel bioprosthetic total artificial heart, in Eur J Cardiothorac Surg2012: Germany. p. e166-72.