Carditis: Inside and Out

Derek Brown, MD

SAUSHEC Military EMS & Disaster Medicine Fellow

Pericarditis

Bruce Blaushttps://commons.wikimedia.org/wiki/File:Pericarditis.png

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

Pericarditis

Not ACS

Not Tamponade

Not Myocarditis

Pericarditis ECG

James Heilman, MDhttps://commons.wikimedia.org/wiki/File:PericarditisMyocarditis.jpg

Pericarditis STEMI

Tamponade

Pericarditis vs Myocarditis

Pericarditis – 70% cases

Myopericarditis – 25% cases

Perimyocarditis – 5% cases

Troponin Elevation:

Ventricular Arrhythmias

Heart Failure

Reduced LVEF

High Risk FeaturesFever >38°C (100.4° F)

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

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

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

Emergency Management

Frank Gaillardhttps://commons.wikimedia.org/wiki/File:AP_portable_CXR_of_a_patient_in_acute_pulmonary_oedema.jpg

Pediatric Series: 45% Significant Arrhythmia

Cardiogenic Shock

Broad Differential

Trial of IV Fluid

Inotropes

Positive Pressure & Invasive Ventilation

Mechanical Circulatory Support

Inotropes Mechanism

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

Regional Care System

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