Rosen & Barkin's 5-Minute Emergency Medicine Consult (469 page)

• EKG:
  
  • Sinus tachycardia most frequent finding
    
  • Transient, nonspecific ST- and T-wave changes
    
  • Atrial and ventricular dysrhythmias
    
  • Heart block and conduction defects:
    
    • 20% have a conduction delay.
      
    • 20% have a left bundle branch block.
      
• CXR:
  
  • Normal cardiac silhouette
    
  • Pulmonary edema
    
  • Pleural effusion
    
• Echocardiogram:
  
  • Impairment of left ventricular systolic and diastolic function
    
  • Segmental wall motion abnormalities
    
  • Impaired ejection fraction
    
  • Pericardial effusion
    
  • Ventricular thrombus has been identified in 15% of patients
    
• Gallium
  ⁶⁷
  and Indium
  ¹¹¹
  -labeled antimyosin antibody scans
  
• Gadolinium-enhanced MRI:
  
  • Indicate cardiac inflammation and myocyte necrosis
    
• Cardiac MRI:
  
  • Abnormal signal areas correlate with regions of myocarditis
    
  • Reported 76% sensitivity, 96% specificity, and 85% diagnostic accuracy
    
  • Considered in patients in whom the diagnosis is unclear and endocardial biopsy is planned
    

• Right ventricular endomyocardial biopsy:
  
  • Appropriate in heart transplant recipients
    
  • Polymerase chain reaction (PCR) amplification of viral genome in endomyocardial tissue
    
• PCR identification of a viral infection from pericardial fluid, or other body fluid sites
  

• Acute MI
  
• Acute and chronic pulmonary embolus
  
• Aortic dissection
  
• Adrenal insufficiency
  
• Environmental challenges
  
• Esophageal perforation/rupture/tear
  
• Hyperpyrexia
  
• Hypothermia
  
• Kawasaki disease
  
• Pericarditis
  
• Pneumonia
  
• Viral
  
• Bacterial
  
• Sepsis
  
• Severe hypothyroidism and hyperthyroidism
  
• Toxin-mediated disease
  

TREATMENT

• ABCs
  
• Supplemental oxygen
  
• Cardiac monitor
  
• Pulse oximetry
  
• IV access
  

• Treat dysrhythmias.
  
• Transthoracic or transvenous pacing for symptomatic heart block
  
• Supplemental oxygen
  
• ACE inhibitors (captopril):
  
  • Reduce afterload and inflammation.
    
• Digoxin:
  
  • CHF or atrial fibrillation
    
• Diuretics (furosemide, bumetanide)
  
• Hyperimmunoglobulin therapy in CMV-associated myopericarditis.
  
• NSAIDs contraindicated in early and acute-phase myocarditis
  
• Heparin and warfarin for patients with depressed LV function or intracardiac thrombus
  

• IV immunoglobulin is an effective treatment option in pediatric viral myocarditis.
  
• Improved LV function and trend toward better survival
  

• Captopril:
  
  • Adult dose: Initial dose 6.25 mg; can titrate to 50 mg/dose
    
  • Pediatric dose:
    
    • Infants: 0.15–0.3 mg/kg/dose (max. 6 mg/kg)
      
    • Children: 0.5–1 mg/kg/24h
      
• Digoxin:
  
  • Adult dose: Load: 0.4–0.6 mg IV, then 0.1–0.3 mg q6–8h. Maintain: 0.125–0.5 mg/d IV/PO
    
  • Pediatric dose:
    
    • <2 yr: 15–20 μg/kg IV
      
    • 2–10 yr: 10–15 μg/kg IV
      
    • >10 yr: 4–5 μg/kg IV
      
• Furosemide:
  
  • Adult dose: 20–80 mg/d PO/IV/IM; titrate up to 600 mg/d for severe edematous states
    
  • Pediatric dose: 1–2 mg/kg PO; not to exceed 6 mg/kg; do not administer >q6h 1 mg/kg IV/IM slowly under close supervision; not to exceed 6 mg/kg
    
• Immunoglobulin IV (Gamimune, Gammagard, Gammar-P, Sandoglobulin):
  
  • Adult dose: 2 g/kg IV over 2–5 days
    

FOLLOW-UP

Symptomatic patients with myocarditis:

• New-onset
  
• CHF
  
• Dysrhythmia
  
• Mobitz II or complete heart block
  
• Embolic events
  
• Cardiogenic shock
  

Asymptomatic patient with no evidence of dysrhythmia or cardiac dysfunction

Cardiac transplant for patients with intractable CHF:

• Approximately 50% of patients die within 5 yr of diagnosis.
  
• Best prognosis for lymphocytic myocarditis
  

• Careful physical exam for signs of CHF and pericarditis is paramount.
  
• EKG should be obtained when considering the diagnosis and is especially sensitive for pediatric cases.
  
• Patients with evidence of dysrhythmia, CHF, or thromboembolism must be admitted.
  

• Brady WJ, Ferguson JD, Ullman EA, et al. Myocarditis: Emergency department recognition and management.
  Emerg Med Clin North Am
  . 2004;22(4):865–885.
  
• Cooper LT. Myocarditis.
  N Engl J Med
  . 2009;360:1526–1538.
  
• Durani Y. Pediatric myocarditis: Presenting clinical characteristics.
  Am J Emerg Med
  . 2009;27(8):942–947.
  
• Magnani JW, Dec GW. Myocarditis: Current trends in diagnosis and treatment.
  Circulation
  . 2006;113:876–890.
  
• Monney PA, Sekhri N, Burchell T, et al. Acute myocarditis presenting as acute coronary syndrome: Role of early cardiac magnetic resonance in its diagnosis.
  Heart.
  2011;97(16):1312–1318.
  

See Also (Topic, Algorithm, Electronic Media Element)

Congestive Heart Failure

CODES

• 074.23 Coxsackie myocarditis
  
• 422.91 Idiopathic myocarditis
  
• 429.0 Myocarditis, unspecified
  

BASICS

• Fractures of nasal skeleton are the most common body fractures.
  
• Most nasal fractures are result of blunt trauma, frequently from motor vehicle crashes, sports injuries, and altercations.
  
• Lateral forces are more likely to cause displacement than straight-on blows.
  
• Characteristics that suggest associated injuries:
  
  • History of trauma with significant force
    
  • Loss of consciousness
    
  • Findings of facial bone injury
    
  • Frontal bone crepitus
    
  • CSF leak
    

• The vast majority of nasal fractures are from direct trauma
  
• Altercations account for most nasal fractures in adults
  
• Direct blows, especially sports, account for most nasal fractures in children
  

DIAGNOSIS