Evaluation And Management Of Pediatric Acute Infectious Myocarditis

During a rare slow evening shift, the triage nurse notifies you that he has just put a sick infant into the resuscitation bay. The parents of the 2-month-old baby boy brought him to the emergency department because he “didn’t look right.” His father reports that for the past 24 hours, his son has been fussy and felt hot to the touch. The family initially attributed the boy’s condition to the recent hot weather, especially because their air conditioner is broken. However, for the past 8 hours, the boy has refused formula, and has started “breathing funny.” As you enter the room, the nurse reports that the patient has a rectal temperature of 38.5°C (101.3°F), that he is unable to obtain a cuff blood pressure, and that the pulse oximeter will not pick-up. You look up at the cardiac monitor to see a heart rate of 205 bpm. The infant is listless and grunting. His extremities are mottled and cold with weakly palpable pulses. Cardiac auscultation is confounded by the baby’s grunting and tachycardia, but there seems to be a systolic murmur. His liver edge is palpable below his umbilicus. What is the etiology of this infant’s shock state? Is he septic? Does he have a ductal dependent congenital heart lesion? Is this a primary dysrhythmia? Does he need a fluid bolus? Should you start a prostaglandin infusion? ... an inotropic infusion? Does he need to be intubated? What drugs should you use for the intubation? You make the decision to intubate him. With judicious use of fentanyl and rocuronium, and with the code cart open and nearby, you successfully intubate him. Despite his poor perfusion, one of the nurses is able to get enough blood for an arterial blood gas and lactate level which reveal a pH of 7.0, PaCO2-50, PaO2-60, and a base deficit of -20, with a lactate level of 15 mmol/L. You alert the on-call cardiologist and the cardiac intensive April 2008 Volume 5, Number 4