Pediatric Viral Myocarditis

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

Clinical Vignette

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?”

Case Summary

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:

sinus-tachy-non-specific-ST-changes

(ECG source: https://lifeinthefastlane.com/ecg-library/myocarditis/)

CXR for the case found here:

cardiomegaly CHF

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/postquestions/posttest.html)

Cardiac U/S for the case found here:

Parasternal Long

(U/S source: http://www.thepocusatlas.com/echo/xg2awokhx1zx8q3ndwjju5cu4t1adq)

Lung U/S for the case found here:

B lines

(U/S source: https://www.thoracic.org/professionals/clinical-resources/critical-care/clinical-education/quick-hits/orthopnea-in-a-patient-with-doxorubicin-exposure.php)

Thyroid Storm

This case is written by Dr. Cheryl ffrench, a staff Emergency Physician at the Health Sciences Centre in Winnipeg. She is the Associate Program Director and the Director of Simulation for the University of Manitoba’s FRCP-EM residency program; she is also on the Advisory Board of emsimcases.com.

Why it Matters

Thyrotoxicosis is a rare presentation to the ED that can masquerade as many other conditions. This case nicely reviews the following:

  • The importance of maintaining a broad differential diagnosis in any patient who presents with an altered level of consciousness and a fever
  • The nuances associated with managing atrial fibrillation in the context of thyrotoxicosis
  • The multiple medications required in order to treat thyroid storm

Clinical Vignette

You are working the evening shift at a tertiary care hospital. A 31-year-old female two weeks postpartum is brought in by EMS accompanied by her husband. He is concerned because she is delirious and somewhat difficult to rouse.

Case Summary

A 31 year-old-female presents by EMS with altered LOC and fever due to thyroid storm precipitated by recent parturition. The patient is tachycardic and hypoxic on arrival. Her level of consciousness will continue to deteriorate despite IV fluids and antibiotics and will require intubation. The husband will be at the bedside, and the team will need to discuss the need for intubation with him. After intubation, lab results will come back indicating possible thyrotoxicosis. The patient’s rhythm will change to atrial fibrillation at this time. The team will be expected to manage the thyroid storm in consultation with Endocrinology and ICU.

Download the case here: Thyroid Storm Case

Sinus tachycardia ECG for the case found here:

Sinus tachycardia

(ECG source: http://lifeinthefastlane.com/ecg-library/hyperthyroidism/)

Atrial fibrillation ECG for the case found here:

rapid-a-fib

(ECG source: http://lifeinthefastlane.com/ecg-library/atrial-fibrillation/)

CHF CXR for the case found here:

severe-chf

(CXR source: http://www.radiologyassistant.nl/en/p4c132f36513d4/chest-x-ray-heart-failure.html)