Recognizing pediatric compensated shock at the earliest opportunity is hard. Usually the cause will be sepsis or dehydration. And the treatment will be straightforward (fluid boluses, IV antibiotics (usually), and vasopressor or inotrope sometimes (noradrenaline in teens and adults [usually warm shock] and epinephrine in children [usually cold shock]).
Recognizing pediatric myocarditis as a cause for uncompensated shock is also very hard. It is a much less common cause than sepsis or dehydration. And the treatment is much more complex. Treatment often requires a complex medical regimen and the ability to provide mechanical circulatory support (with ventricular assist device or ECMO) as these patients can deteriorate suddenly.
In this post we look briefly at Dr. Towbin’s grand rounds talk and then at Dr. Helman’s podcast.
Resource (1) below, “Myocarditis in Children: 2016,” Jeffrey Towbin, M.D. 59:30 YouTube Video, is a complete grand rounds on pediatric myocarditis.
Dr. Towbin presents two cases of pediatric myocarditis. The first is an acute myocarditis in a 6 week old infant. And the second is 16 year old with chronic myocarditis.
When pediatric myocarditis is suspected (rales, hepatomegally, mitral insufficiency murmur, or clinical course following initial therapy) the following studies are indicated: CXR, ECG, CBC with Differential, B-type natriuretic peptide (to differentiate respiratory failure [normal level] from heart failure [elevated level]), troponin (can be elevated in coronary artery inflammation in parvovirus), blood and peripheral cultures, viral serologies and an echocardiogram.
As soon as pediatric myocarditis is strongly suspected, you want to be working on quickly transferring the patient from your local facility to a very specialized pediatric cardiology center. The accepting facility should have the capability of supporting the patient with a ventricular assist device, complex medical therapy, and if things go very badly then extracorporeal membrane oxygenation (ECMO).
If a patient deteriorates in a local facility without the above capabilities, the patient will most likely not survive.
Dr. Towbin’s lecture is very complete and worth listening to if you have the time.
Now we’ll turn to Dr. Helman’s podcast. Resource (2) This is the second case discussed by Drs. Helman, DeCaen, and Crocco in the podcast Episode #93 [link is to the podcast and shownotes] from Emergency Medicine Cases.
Now Dr. Anton Helman describes the second case:
A four-year-old fully immunized girl presents to your ED with 24 hours of increasing irritability, lethargy, fever, and rapid breathing. On exam she appears diaphoretic and in severe respiratory distress with prolonged capillary refill.
She has extreme tachycardia and dyspnea with the normal blood pressure. She has an oxygen saturation of 89% on room air. The temp is 39°C.
You call for 20 mL of normal saline IV bolus per kilogram and ceftriaxone for presumed sepsis.
As you’re sorting out the imaging, you notice her respiratory rate increasing and her oxygen saturation dropping.
Your resident, who is doing a head to toe assessment, notices an enormous liver.
You pull out your ultrasound and place the probe on her lungs and defined it b lines.
So Dr. Crocco what are you thinking about in terms of the most likely diagnosis now in this patient and how will you manage the situation?
And Dr. Crocco replies:
So this is a clear case of things not going the way that I planned. And this happens often in 6he emergency department setting where you make a diagnosis and you start a therapeutic algorithm and things are going the way that you planned.
For me when I’m walking down that path I think either I’ve made the right diagnosis and I’m doing the right thing just not doing enough of it or there’s something else going on that I haven’t quite identified and I’m doing the wrong thing.
In this case the second possibility is what were dealing with. And there may be an element of sepsis here but likely there is an element of cardiac failure likely mediated by myocarditis or some sort of internal cardiac issue.
And Dr. Helman states, yes myocarditis is one of the things that scares the heck out of me because it’s a very difficult diagnosis to make but it’s one of those things that we always have to remember, especially in children because it is one of the more common causes of cardiac arrest in children.
And Dr. Crocco says that yes of these kids scare me a lot too.
Dr. Helman goes on: so we have this child who now seems like they are in congestive heart failure and septic, let’s continue the case. So despite your best efforts this child ends up deteriorating, gets innovated and now is hypotensive with frothing at the tube.
You put in a call to your pediatric intensivist and you suction the tube. You call for epinephrine but your patient still ends up going into a PEA arrest.
You go through your usual PALS algorithm and your astute resident asks you: is this patient a candidate for ECMO.
And so Dr. Hellman asks Dr. DeCaen: what is the role of ECMO in pediatric cardiac arrest?
The bottom line is – as soon as a patient is strongly suspected of having pediatric myocarditis – the patient should be transferred to a pediatric center that has the capabilities of ventricular assist devices, complex medical therapy, and, if needed, ECMO.
If a patient with pediatric myocarditis deteriorates in a facility without the above capabilities, the patient will likely not survive.
Resources:
(1) “Myocarditis in Children: 2016,” Jeffrey Towbin, M.D. 59:30 YouTube Video. ETSU CME Grand Rounds, Published on Apr 20, 2016
(2) Episode 93 – PALS Guidelines, March 2017 from Emergency Medicine Cases.
