Carditis: Inside and Out. Derek Brown, MD SAUSHEC Military EMS & Disaster Medicine Fellow

Transcription

1 Carditis: Inside and Out Derek Brown, MD SAUSHEC Military EMS & Disaster Medicine Fellow

2 Pericarditis Bruce Blaus

3 Pericarditis 0.1% of Hospitalized Patients 5% of ED Patients with non-acs CP 80-90% Viral Complications: 21% Patients 18% recurrence 3-5% tamponade 2% constrictive pericarditis

4 Pericarditis Not ACS Not Tamponade Not Myocarditis

5 Pericarditis ECG James Heilman, MD

6 Pericarditis STEMI

7 Tamponade

8 Pericarditis vs Myocarditis Pericarditis 70% cases Myopericarditis 25% cases Perimyocarditis 5% cases Troponin Elevation: Ventricular Arrhythmias Heart Failure Reduced LVEF

9 Fever >38 C (100.4 F) High Risk Features Subacute Course (several days weeks) Cardiac Tamponade Large Pericardial Effusion (end-diastole Echo-free space >20mm) Immunosuppression / Immunocompromised Anticoagulation Use Trauma Failure of NSAID and/or Colchicine Elevated Troponin

10 Myocarditis Variable Presentation: Viral Illness Cardiogenic Shock 41 89% Viral Prodrome Enterovirus, Adenovirus, Parvo B19, HHV 6 Severe Myocarditis 5yr Survival: 56% Pediatric: 90% with 80% requiring ICU care

11 Myocarditis Presentation Pediatric Series: 45% Chest Pain 28% Resp. Distress 27% GI Sx 16% Poor Perfusion 41% Viral Prodrome Key Features: - EKG Changes of Myocardial Injury - Rise in Troponin - Arrhythmia - New/Unexplained Cardiac Dysfxn - Tachycardia Out-Of-Proportion

12 Emergency Management Pediatric Series: 45% Significant Arrhythmia Frank Gaillard te_pulmonary_oedema.jpg

13 Cardiogenic Shock Broad Differential Trial of IV Fluid Inotropes Positive Pressure & Invasive Ventilation Inotropes Mechanis m Effect Adverse Dobutamine Inodilator Contract SVR Hypotension Milrinone Inodilator Contract SVR Hypotension Dopamine Mixed Contract SVR Arrhythmia, Mortality Norepinephrine Inopressor Contract SVR Epinephrine Inopressor Contract SVR Tachycardia, Arrhythmia Mechanical Circulatory Support

14 Regional Care System

15 References: Baselet B, Rombouts C, Benotmane AM, Baatout S, Aerts A. Cardiovascular diseases related to ionizing radiation: The risk of low-dose exposure (Review). International Journal of Molecular Medicine. 2016;38(6): doi: /ijmm Bergmann, K. R., Kharbanda, A., & Haveman, L. (2015). Myocarditis And Pericarditis In The Pediatric Patient: Validated Management Strategies. Pediatric emergency medicine practice, 12(7), Davies, P., & Maconochie, I. (2009). The relationship between body temperature, heart rate and respiratory rate in children. Emergency Medicine Journal, 26(9), De Backer, D., et al. (2010). Comparison of dopamine and norepinephrine in the treatment of shock. New England Journal of Medicine, 362(9), Ghelani, S. J., et al. (2012). Demographics, trends, and outcomes in pediatric acute myocarditis in the United States, 2006 to Circulation: Cardiovascular Quality and Outcomes, 5(5), Grogan, M., et al. (1995). Long-term outcome of patients with biopsy-proved myocarditis: comparison with idiopathic dilated cardiomyopathy. Journal of the American College of Cardiology, 26(1), Imazio, M., et al. (2003). Cardiac troponin I in acute pericarditis. Journal of the American College of Cardiology, 42(12), Imazio, M., et al. (2004). Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. Journal of the American College of Cardiology, 43(6), Imazio, M., et al. (2007). Indicators of poor prognosis of acute pericarditis. Circulation, 115(21), Kytö, V., Sipilä, J., & Rautava, P. (2014). Clinical Profile and Influences on Outcomes in Patients Hospitalized for Acute Pericarditis CLINICAL PERSPECTIVE. Circulation, 130(18), % hosp pts Levy, B., Perez, P., Perny, J., Thivilier, C., & Gerard, A. (2011). Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic shock. A prospective, randomized pilot study. Critical care medicine, 39(3), Mason JW, O'Connell JB, Herskowitz A, et al. A clinical trial of immunosuppressive therapy for myocarditis. The Myocarditis Treatment Trial Investigators. N Engl J Med 1995; 333:269. O Connell, J. B., & Topol, E. J. (1998). Diagnosis and medical treatment of inflammatory cardiomyopathy. Topol et al. Cardiovascular Medicine. Philadelphia: Lipincott-Raven. Rossello, X., et al. (2014). New electrocardiographic criteria to differentiate acute pericarditis and myocardial infarction. The American journal of medicine, 127(3), van Diepen, S., Katz, J. N., Albert, N. M., Henry, T. D., Jacobs, A. K., Kapur, N. K.,... & Thiele, H. (2017). Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association. Circulation, 136(16), e232-e268.