Congestive Charlie

[Aussieaid]

It notes that left ventricular failure should be treated in-hospital with IV nitrates, duiretics and vasodialstors where feasible.

Note here its right ventricular failure or could be complete heart failure but it's not like we can do an echo or other cardiac imaging to differentiate betweeen complete heart failure and cardiogenic shock caused by right ventricular failure.

It is pretty clear by the symptoms without an echo that he has complete heart failure and is already going into cardiogenic shock as evidenced by the peripheral edema, JVD, (right sided failure) pulmonary edema and hypotension. (left sided failure and shock). What we can't tell prehospital is the exact cause although the temperature, history of being sick for a few days, cardiac irritability without obvious ST changes narrows down our differentials.

Before it gets taken wrong I completely agree (as previously stated) that this patient was stable enough to not mess with him and the treatments I suggested are treatments that would be implemented in the hospital unless he deteriorated before we could get him there.

The patient had a cardiomyopathy from the myocarditis and it presents as complete heart failure (Both right and left sided failure). The note about treating myocarditis like left ventricular failure is after initial stabilization where they go to ACEI. The treatment for CHF and cardiomyopathy with or without cardiogenic shock which presents as both right and left sided failure is slightly different to just right sided failure which is totally preload dependent.

Supportive care is the first line of treatment. A minority of patients who present with fulminant or acute myocarditis will require an intensive level of hemodynamic support and aggressive pharmacological intervention, including vasopressors and positive inotropic agents, similar to other patients with advanced heart failure due to profound left ventricular dysfunction. Elevated ventricular filling pressures should be treated with intravenous diuretics and vasodilators (when feasible) such as nitroprusside or intravenous nitroglycerin. A ventricular assist device or extracorporeal membrane oxygenation may rarely be required to sustain patients with refractory cardiogenic shock.108 These devices favorably alter ventricular geometry, reduce wall stress, decrease cytokine activation, and improve myocyte contractile function. Although the data on survival after ventricular assist device or extracorporeal membrane oxygenation implantation are largely observational, the high likelihood of spontaneous recovery of ventricular function argues for aggressive short-term hemodynamic support

Good discussion and case study,

Thanks and Cheers!

Edited January 25, 2010 by Aussieaid

[Kiwiology]

Yeah if this guy started to crash I'd get into the drug roll otherwise the agreeable consensus is on supportive care.

I was more interested to see how many would dip into the tacklebox without considering that it can do more harm than good in a case like this.

The way various standing orders are written and ambo's are taught leaves something to be desired here too, ours for example make no mention of it. I know it SHOULD be known by virtue of education, but well, so much for education in some cases.

Now it may be implied that out there in the periphery ambos should spot the larger clinical signs and not load our man up on GTN, fluids, morphine and frusemide but we both know there are ambos out there who have no peripheral vision whatsoever!

Me however, I'm just a blind bastard plain and simple!

Edited January 25, 2010 by kiwimedic

[DwayneEMTP]

...How can they take away heart tones? Doesn't make much sense to me...

Holy crap, that's funny as hell right there....

Dwayne

[DartmouthDave]

Hello,

I wanted to add an artcile on Myocarditis from Up To Date but it was too big.

However, he is a slightly related one on RVI that is interesting.

Edited January 27, 2010 by DartmouthDave

[jvelasquez]

You're sent two suburbs over to pick up Charlie fron a walk in medical centre and take him to the hospital.

- 84 year old male complaining of severe SOB

- Immeadiate hx of feeling sick for 5 days, no significant prior history

- Looks sick; pale, sweaty, nauseous, feels fluey, markedly increased work of breathing

- HR 63, RR 24 laboured, mid & basal crackles, speaks 4-5 words per sentance, temp 38.5°, ECG new onset 1° AVB with bigeminy PVCs

- No meds, NKA

The doctor is trying to find some chest films he took and it'll take a minute or two.

This is a two part scenario:

a) BP is 96/86, how do you treat?

a) If BP was 136/96, how would that alter your treatment?

[Kiwiology]

Did you mean to add something here? .....