This issue includes 4 hours of ACEP/AMA category 1 CME credit.
Authors: Robert Mazor, MD and Jack C. Salerno, MD
Peer Reviewers: Ran Goldman, MD and Marc S. Lampell, MD
Publication Date: April 1, 2008
Excerpt from the issue… During a rare slow evening shift, the triage nurse notifies you that he has just put a sick infant into the resuscitation bay. The parents of the 2-month-old baby boy brought him to the emergency department because he “didn’t look right.” His father reports that for the past 24 hours, his son has been fussy and felt hot to the touch. The family initially attributed the boy’s condition to the recent hot weather, especially because their air conditioner is broken. However, for the past 8 hours, the boy has refused formula, and has started “breathing funny.”
As you enter the room, the nurse reports that the patient has a rectal temperature of 38.5°C (101.3°F), that he is unable to obtain a cuff blood pressure, and that the pulse oximeter will not pick-up. You look up at the cardiac monitor to see a heart rate of 205 bpm. The infant is listless and grunting. His extremities are mottled and cold with weakly palpable pulses. Cardiac auscultation is confounded by the baby’s grunting and tachycardia, but there seems to be a systolic murmur. His liver edge is palpable below his umbilicus. What is the etiology of this infant’s shock state? Is he septic? Does he have a ductal dependent congenital heart lesion? Is this a primary dysrhythmia? Does he need a fluid bolus? Should you start a prostaglandin infusion? an inotropic infusion? Does he need to be intubated? What drugs should you use for the intubation?
You make the decision to intubate him. With judicious use of fentanyl and rocuronium, and with the code cart open and nearby, you successfully intubate him. Despite his poor perfusion, one of the nurses is able to get enough blood for an arterial blood gas and lactate level which reveal a pH of 7.0, PaCO2-50, PaO2-60, and a base deficit of -20, with a lactate level of 15 mmol/L. You alert the on-call cardiologist and the cardiac intensive care service, and suggest that they mobilize the Extracorporeal Life Support (ECLS) team. The patient’s chest radiograph demonstrates cardiomegaly and pulmonary edema. The electrocardiogram (ECG) demonstrates sinus tachycardia. The echocardiogram demonstrates severe globally depressed biventricular function with moderate mitral regurgitation. Should the patient be placed on extracorporeal membranous oxygenation (ECMO) immediately? Which inotropic infusion should you start in the mean time? dopamine? Dobutamine? milrinone? You decide to start him on a dobutamine infusion.
Conclusion to the above case study... Your patient is transferred to the Cardiac Intensive Care unit. He fails initial attempts at medical management and is placed on ECMO. The following day, the service is notified that blood, rectal, and nasopharyngeal specimens are all positive for enteroviral ribonucleic acid (RNA) as determined by polymerase chain reaction (PCR).
The patient remains on ECMO for 5 days, is successfully weaned and decannulated on day 6, and is ultimately discharged from the hospital after a few weeks. He has regular cardiologic follow-up for mild residual left ventricular dysfunction, though he remains asymptomatic and is growing well.
About this article: In this issue of Pediatric Emergency Medicine Practice, we will review an evidence-based approach to the evaluation and treatment of children with acute infectious myocarditis. The ED physician should have a high index of suspicion for the disease when caring for infants and children with viral symptomatology, especially when their intuition tells them, “Something is not quite right with the patient.” While much of the management of the disease is supportive, early and accurate diagnosis and treatment are paramount for a favorable outcome.
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