This case is written by Dr. Adam Cheng. Adam Cheng, MD, FRCPC is Associate Professor, Departments of Paediatrics and Emergency Medicine at the Cumming School of Medicine, University of Calgary. He is also Scientist, Alberta Children’s Hospital Research Institute and Director, KidSIM-ASPIRE Simulation Research Program, Alberta Children’s Hospital. Adam is passionate about cardiac arrest, resuscitation, simulation-based education and debriefing. The case has been modified by Drs. Dawn Lim, Andrea Somers, and Nadia Farooki for use at the University of Toronto.
Why it Matters
Myocarditis is a presentation that can be challenging to recognize early. It is often mistaken simply for septic shock. This case highlights some important features of the recognition and management of myocarditis, including:
- The need to re-evaluate the differential in a patient with persistent hypotension
- The role of bedside tests in aiding the diagnosis (ECG, POCUS, CXR)
- The importance of re-evaluating and re-assessing a patient and adjusting the differential diagnosis and management accordingly
You are working in a large community ED. The charge nurse tells you: “EMS have just arrived with a 15-year old boy with shortness of breath and chest pain. His O2 sat is low. EMS have administered oxygen and IVF en route. He looks unwell so I put him in a resuscitation room. Can you see him immediately?”
A 15 year-old male with no prior medical history is brought to the ED by his parents for lethargy, shortness of breath and chest pain. He was feeling run down for the past 4 days with URTI symptoms.
His initial presentation looks like sepsis with a secondary bacterial pneumonia. He becomes hypoxic requiring intubation. He develops hypotension that does not respond as expected to fluids and vasopressors, which should prompt more diagnostics from the team.
Further testing reveals cardiomyopathy with reduced EF and acute CHF. He finally stabilizes with inotropes and diuresis.
Download the case here: Pediatric Viral Myocarditis
ECG for the case found here:
(ECG source: https://lifeinthefastlane.com/ecg-library/myocarditis/)
CXR for the case found here:
(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/postquestions/posttest.html)
Cardiac U/S for the case found here:
(U/S source: http://www.thepocusatlas.com/echo/xg2awokhx1zx8q3ndwjju5cu4t1adq)
Lung U/S for the case found here:
(U/S source: https://www.thoracic.org/professionals/clinical-resources/critical-care/clinical-education/quick-hits/orthopnea-in-a-patient-with-doxorubicin-exposure.php)