Carditis: Inside and Out

Derek Brown, MD SAUSHEC Military EMS & Disaster Medicine Fellow Pericarditis

Bruce Blaus https://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, MD https://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 Features Fever >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: Key Features: 45% Chest Pain - EKG Changes of Myocardial 28% Resp. Distress Injury 27% GI Sx - Rise in Troponin 16% Poor Perfusion - Arrhythmia 41% Viral Prodrome - New/Unexplained Cardiac Dysfxn

- Tachycardia Out-Of-Proportion Emergency Management

Pediatric Series: 45% Significant Arrhythmia

Frank Gaillard https://commons.wikimedia.org/wiki/File:AP_portable_CXR_of_a_patient_in_acu te_pulmonary_oedema.jpg Cardiogenic Shock

Broad Differential Inotropes Mechanis Effect Adverse m Trial of IV Fluid Dobutamine Inodilator ↑Contract ↓SVR Hypotension Milrinone Inodilator ↑Contract ↓SVR Hypotension Inotropes Dopamine Mixed ↑Contract ↑↓SVR Arrhythmia, ↑ Mortality Norepinephrine Inopressor ↑Contract ↑SVR Positive Pressure Epinephrine Inopressor ↑Contract ↑SVR Tachycardia, Arrhythmia & Invasive Ventilation

Mechanical Circulatory Support Regional Care System References:

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