Setup

Chief complaint: Lethargy, shortness of breath
Patient age: 10 years old
Weight: 32 kg

Recommended Supplies

• Manikin: child
• Moulage: none
• Resources: PALS cards and/or length-based tape (e.g., Broselow Tape)
• Manikin set up: No access in place at start of case, drain bag in place
• Equipment:
  • IV supplies
  • Cardiac monitor
  • Ultrasound machine
  • Pediatric Airway Equipment:
    • Nonrebreather mask
    • End tidal CO2 monitor
    • BMV with different size masks
    • Oxygen tubing
  • Non-invasive positive pressure such as BiPAP
• Medications:
  • Epinephrine – code dose and drip
  • Dobutamine
  • Norepinephrine
  • Milranone
  • Antibiotics
  • Crystalloid (e.g., normal saline)

Supporting Files

• CXR: Cardiomegaly, pulmonary edema
• ECG: Left axis deviation, with non-specific ST segment changes
• Labs
• Echocardiogram: Poor LV function

Participants/Roles

• Team leader
• Airway manager
• Survey physician
• Medication preparer
• Medication giver
• Family liaison/history taker
• Standardized patient (actor or faculty) to play patient’s parent

* Team roles may need to be adjusted in order to suit local practices and norms

Faculty or other embedded participants can play a nurse, respiratory therapist, or tech, if there are not enough learners to perform the above roles.

Prerequisite Knowledge

• Faculty
  • PALS protocols
  • General knowledge of emergency medicine
  • Simulation implementation and debriefing experience

• Emergency medicine residents
  • Any stage of training (preferably PGY-2 or higher)
  • Completed PALS certification
  • Bedside cardiac ultrasound knowledge

Case Alternatives

• The patient could go into cardiac arrest at several points during the case:
  • If team attempts intubation, especially if inotropic medication have not been given
  • Anytime during the case, the patient may go into a ventricular arrhythmia without pulses requiring 1 round of epinephrine and 1 round of unsynchronized defibrillation at 2 J/kg.

Milestones

PC1. Emergency Stabilization
PC2. Performance of Focused History & Physical Exam
PC3. Diagnostic Studies
PC4. Differential Diagnoses and Management
PC5. Pharmacotherapy
PC7. Disposition
PC12. Goal-directed Focused Ultrasound (Diagnostic/Procedural)
ICS1. Patient Centered Communication
ICS2. Team Management

Resources

1. Canter CE, Simpson KE. Diagnosis and treatment of myocarditis in children in the current era. Circulation. 2014;129:115-128. PMID: 24396015
2. Tunuguntla H, Jeewa A, Denfield SW. Acute myocarditis and pericarditis in children. Pediatric in Review. 2019;40:14-25. PMID: 30600275
3. Horeczko T. Myocarditis. Pediatric Emergency Playbook. 2019.
4. Pomiato E, Perrone MA, Palmieri R, Gagliardi MG. Pediatric Myocarditis: What Have We Learnt So Far? J. Cardiovasc Dev Dis. 2022, 9, 143. DOI: 10.3390/jcdd9050143
5. Law YM, Lal AK, Chen S, et al. Diagnosis and Management of Myocarditis in Children: A Scientific Statement From the American Heart Association [published correction appears in Circulation. 2021 Aug 10;144(6):e149]. Circulation. 2021;144(6):e123-e135. PMID: 34229446
6. Putschoegl A, Auerbach S. Diagnosis, Evaluation, and Treatment of Myocarditis in Children. Pediatr Clin North Am. 2020 Oct;67(5):855-874. doi: 10.1016/j.pcl.2020.06.013. Epub 2020 Aug 10. PMID: 32888686
7. Kittleson MM. An Update on Pediatric Myocarditis Using the New AHA Scientific Statement (No.17). In HeartBEATS from Lifelong Learning TM, Science Series. Nov 15, 2021.
8. Mick NW, Williams RJ. Pediatric Cardiac Arrest Resuscitation. Emerg Med Clin North Am. 2020 Nov;38(4):819-839. doi: 10.1016/j.emc.2020.06.007. Epub 2020 Sep 9. PMID: 32981620
9. Kelly JM, Welsch SS, Chui C, Berk J. “Shock! A Deep Dive into Our First Intensive Topic.” The Cribsiders Pediatric Podcast. June 9, 2021.

Cardiogenic Shock (Initial Presentation)

Start through review of ECG and/or CXR

Critical Actions

• Team leader identifies patient is high acuity
• Team leader asks for help and assigns roles
• Obtain history from parent
• Perform primary survey
• Administer supplemental oxygen
• Place patient on continuous cardiac monitor
• Obtain vascular access
• Perform focused physical exam and recognizes right sided crackles (+/-liver edge)
• Order diagnostic tests (ECG, CXR, labs)
• Verbalize recognition of compensated shock from exam and monitors
• Discuss progress and plan of care with the parent (and involves them in decision-making)

Physical Exam

Instructor Notes: Changes and Case Branch Points

Cardiogenic shock (Decompensated):

Review diagnostic tests through initiation of vasopressors OR intubation without vasopressors

Critical Actions

• Verbalize the recognition of cardiogenic shock
• Perform bedside cardiac ultrasound
• Start pressor/inotropic agent (e.g., epinephrine, dobutamine, norepinephrine, milrinone)

* Unbolded items may be excluded depending on local practices and norms

Physical Exam

Instructor Notes: Changes and Case Branch Points

Ventricular Tachycardia With Pulses

Initiation of vasopressors (or intubation without vasopressors) through synchronized cardioversion with vasopressors

Critical Actions

• Place defibrillator pads on patient
• Perform synchronized cardioversion

Physical Exam

Instructor Notes: Changes and Case Branch Points

Stabilization and Conclusion

After pressors started (or optionally after cardioversion)

Critical Actions

• Verbalize concern for myocarditis
• Consult pediatric cardiology
• Transfer care of the patient to the pediatric ICU
• Address parental concerns and questions

* Unbolded items may be excluded depending on local practices and norms

Physical Exam

Instructor Notes: Changes and Case Branch Points

Describe the signs/symptoms of shock in a child (comprehension)

Children tend to compensate well initially. In compensated shock, homeostatic mechanisms help maintain systolic blood pressure within the normal range for age. To compensate, the heart rate will increase, and peripheral vasoconstriction occurs. Findings on exam may include delayed capillary refill, diminished pulses, and cool extremities. Urine output decreases as perfusion to the kidneys decreases. Once compensatory mechanisms have been exhausted, uncompensated shock occurs. Systolic hypotension and altered mental status from brain hypoperfusion occur. Decreased respiratory drive can occur as cardiovascular collapse ensues.

Demonstrate early evaluation of a critically ill patient (application)

Learners should approach a critically ill patient in a standardized fashion. Airway, breathing, and circulation should be assessed immediately. Interventions such as airway repositioning/adjuncts, BMV, and CPR should be started concurrently, if required. After A, B, C have been addressed, the patient should be evaluated for disability and exposed for a thorough head to toe exam. In pediatrics, people often say that D also stands for “don’t forget the dextrose” as a blood glucose level should be checked in any child with altered mental status.

Construct a differential diagnosis for shock in a pediatric patient (synthesis)

The 4 general categories of shock include distributive (warm shock), hypovolemic, obstructive, and cardiogenic (typically cold shock). Sepsis is the most common cause of distributive shock in children. Anaphylactic shock may present with or without a previously known allergy. Neurogenic shock is very rare in children. Hypovolemic shock is the most common cause of pediatric shock worldwide. Obstructive shock may present in the setting of the ductus arteriosus closing in the presence of a ductal dependent lesion (e.g., coarctation, hypoplastic left heart) or from acute obstruction of cardiac outflow (e.g., tension pneumothorax, tamponade, massive pulmonary embolism). Cardiogenic shock may occur from either an arrhythmia that leads to insufficient cardiac output or from a cardiomyopathy (genetic, infectious, infiltrative, ischemic) including myocardial depression related to sepsis.

Interpret the signs/symptoms of myocarditis (evaluation)

The signs and symptoms of myocarditis are usually vague initially and similar to those of viral syndromes. Many children less than 10 years old will experience respiratory (e.g., cough, shortness of breath, tachypnea) and/or GI symptoms (e.g., abdominal pain, nausea, vomiting). Children older than 10 years often complain of symptoms that are more obviously cardiac in origin such as palpitations, chest pain, and syncope. General symptoms such as lethargy and fever may also be reported.

There is no specific laboratory test for myocarditis. AST will be elevated in a majority of cases (85% of patients), due to hepatic congestion. Troponin and BNP are elevated in a majority of cases, but not all, so a negative test does not rule out the disease. Inflammatory markers might be elevated. A chest radiograph is abnormal in approximately 50% of children with myocarditis and may show cardiomegaly and/or pulmonary edema/venous congestion. An ECG is usually abnormal, but changes are generally non-specific. It may reveal diminished voltage, ST segment or T-wave changes, atrial or ventricular enlargement, premature beats, or heart block. An echocardiogram usually shows impaired ventricular function. Definitive diagnosis is often made by endomyocardial biopsy.

Compare and contrast the signs and symptoms of cardiogenic shock relate to other causes of shock (evaluation)

While cardiogenic shock shares many features of other causes of shock (tachycardia, hypotension, altered mental status, lactic acidosis, decreased urine output), some features are more suggestive of a cardiac etiology. These include signs of “pump failure” such as a gallop (typically S3), pulmonary edema, hepatomegaly. An elevated JVP may be seen in older children/teenagers but is often difficult to impossible to appreciate in young children due to the size and shapes of their necks. The patient will likely demonstrate further deterioration with aggressive fluid boluses, highlighting the importance of reassessment of interventions and smaller fluid boluses (10 mL/kg), if cardiogenic shock is suspected.

Construct and implement initial medical management of cardiogenic shock (application)

Initial management should be aimed at increasing cardiac output. In the case of a ductal-dependent lesion, PGE-1 should be started expeditiously. In the setting of decreased myocardial functioning, inotropes may be used to increase cardiac output while vasopressors may help maintain systemic venous return. Epinephrine, dobutamine, and milrinone will all increase output while norepinephrine will promote SVR. Dopamine has been associated with increased mortality in cardiogenic shock compared to norepinephrine (study in adults). Decreasing metabolic demand is also an important initial step. Fever should therefore be treated. Positive pressure ventilation including potential intubation may be required. However, catastrophic myocardial depression may occur during induction and therefore non-emergent intubation should be done in consultation with a pediatric cardiologist.

Demonstrate focused history taking from a caregiver (application)

The history should be focused during the initial evaluation and explore possible etiologies of shock. The symptoms of cardiogenic shock are often vague so review of systems should focus on recent cardiac, pulmonary, and GI symptoms. Inquiry should focus on recent illnesses/infection symptoms, recent vaccinations (COVID-19), potential exposure to ingestions or toxins, and potential causes of immunocompromise. A vaccination history should be obtained. Medications and allergies should be inquired about, just like for all patients.

Explain diagnosis and management to caregivers (synthesis)

If personnel are available, one member of the team may stay with the family to gather history and explain interventions. Information should be relayed to the family using layperson’s terms. The rationale for invasive interventions such as IV placement should be explained preceding or at the time of occurrence, when possible. The results of diagnostic tests and imaging should be relayed to the family in a timely fashion.

Demonstrate teamwork and closed loop communication (application)

Teams may use different frameworks to improve team dynamics and communication. Below are a few definitions that may be helpful to discuss, adapted from the AHRQ TeamSTEPPS Pocket Guide.

• Brief: Short session prior to start of encounter to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies
• Huddle: Ad hoc team discussion to re-establish Situation Awareness; designed to reinforce plans already in place and assess the need to adjust the plan
• Callout: A strategy used to communicate critical information during an emergent event. Helps the team prepare for vital next steps in patient care. (Example: Leader- “Airway status?”; Surveying provider- “Airway clear”; Leader- “Breath sounds?”; Surveying provider- “Breath sounds decreased on right”)
• Check-back: A closed-loop communication strategy that requires a verification of information ensuring that information conveyed by the sender is understood by the receiver as intended. The sender initiates the message; the receiver accepts it and restates the message. In return, the sender verifies that the re-statement of the original message is correct or amends if not. (Example: Leader- “Give diphenhydramine 25 mg IV push”; Med Prep- “Diphenhydramine 25 mg IV push”; Leader- “That’s correct”)
• SBAR: A framework for team members to structure information when communicating to one another.
  • S = Situation (What is going on with the patient?)
  • B = Background (What is the clinical background or context?)
  • A = Assessment (What do I think the problem is?)
  • R = Recommendation (What would I do to correct it?)
• Situation monitoring: The process of continually scanning and assessing a situation to gain and maintain an understanding of what is going on around you.
• Situation awareness: The state of “knowing what’s going on around you.”
• Shared mental model: Result of each team member maintaining situation awareness and ensures that all team members are “on the same page.” An organizing knowledge structure of relevant facts and relationships about a task or situation that are commonly held by team members.
• STEP: A tool for monitoring situations during complex situations. A systematic method to review Status of patient, Team members’ performance and status, Environment, and Progress towards goal.
• Cross-monitoring: A harm error reduction strategy that involves 1. Monitoring actions of other team members 2. Providing a safety net within the team. 3. Ensuring that mistakes or oversights are caught quickly and easily. 4. “Watching each other’s back.”
• CUS: Signal phrases that denote “I am Concerned,” “I am Uncomfortable,” and “This is a Safety Issue.” When spoken, all team members should understand clearly not only the issue but also the magnitude of the issue.

Chest X-ray

ECG

Cardiac Ultrasonography

Download Case 8 supporting files

Notes:

• CXR Interpretation: Chest x-ray with cardiomegaly and pulmonary edema. Image from Dr. Rebekah Burns.
• ECG Interpretation: ECG with left axis deviation and non-specific ST segment changes. Image from Dr. Rebekah Burns. (Additional ECGs can be found at Life in the Fast Lane.)
• Ultrasounds: All images show wall motion abnormalities with global myocardial dysfunction. Courtesy of New-York Presbyterian Brooklyn Methodist Hospital POCUS Division.

For the embedded participant playing the patient’s parent

Case Background Information

Your son has myocarditis, or inflammation of his heart that can make it function poorly. This can come on after a viral infection and can have very vague symptoms. Oftentimes, children are fatigued, breathing fast, have low blood pressures, and appear pale because they are not able to circulate blood effectively due to their heart not pumping well. They can present similarly to how someone in shock due to an infection can look. The treatment for myocarditis is to start vasopressors that help improve cardiac output (the amount of blood pumped from the heart). It is important to avoid giving too much fluid because this can overload the heart. Sometimes this can happen when the diagnosis is not clear and learners are trying to treat shock due to infections.

You are bringing your son to the Emergency Department because he has been very tired, short of breath, and pale appearing. He was at his father’s house over the weekend so at first you thought he was just tired from too many activities; however, when he wouldn’t wake up easily from a nap, and you noticed him breathing hard, you brought him to the ED.

Who are the Learners?

Emergency medicine residents

This case is specifically aimed at second year residents who have had one year of experience in gathering information from patients and families and performing standard medical treatments and procedures. They should be familiar with going through a differential diagnosis of the various things that may be going on and recognizing sick patients. They should also be familiar with keeping families informed of decision making and explaining interventions.

Standardized Patient Information

You brought your son to the emergency department because he is tired, not wanting to wake up and breathing fast. He was fine when you dropped him at his dad’s house 2 days ago.

Your demeanor is concerned but more for an illness that may need some antibiotics by mouth, as opposed to anything too serious. You are confused as to why the patient needs so many people and interventions. Do not interrupt them if they are thinking out loud or discussing care with one another but ask questions when possible if they don’t explain what they are doing. Voice concern as to whether the patient needs everything they are doing.

Patient Information

(Please remember not to offer any of this information, but when asked please respond while remaining in character.)

• CHIEF COMPLAINT (your response to open-ended questions such as “what’s going on?” or “what can we do for you? Or “what happened?”): “He just seems really tired and under the weather.”
• AGE: 10 years old
• ADDITIONAL HISTORY: You first state that he was tired around 9 am but thought he had just stayed up late. He took a nap right when you picked him up from his dad’s. Around noon you went to check on him because he hadn’t woken up. He was cool and clammy and looked like he was breathing hard. At first, you thought he may have a cold virus and tried an albuterol treatment. This didn’t seem to help too much, and he wanted to go right back to sleep. You decided to bring him in to be checked out. No other medication was given, and you didn’t check a temperature at home. He had a cold a few weeks ago but seemed to be better prior to today.
• PAST MEDICAL HISTORY: Mild asthma
• SOCIAL HISTORY: Lives with you most of the time. Spends every other weekend with dad. Does not smoke.
• FAMILY HISTORY: Unremarkable
• PAST SURGICAL HISTORY: None
• MEDICATIONS: Albuterol every 4 hours, as needed
• ALLERGIES: No known drug allergies
• IMMUNIZATIONS: Up-to-date

Potential Dialogue

IMPORTANT: Do not offer unsolicited information. Please allow the learners to ask questions. Do not offer information unless they ask you.

Things you might say triggered by events in the scenario:

• “He just seems so tired.”
• “Usually the albuterol helps but this time it didn’t seem to.”

Things you might say triggered by events in the scenario:

The team enters the room and immediately recognizes that the patient appears to be sick with evidence of shock. They place the patient on oxygen and call for additional support. The team completes a physical exam and recognizes crackles and hepatomegaly. An IV is placed, and 10-20 mL/kg fluid bolus is given for shock. The team recognizes a worsening exam after the IV fluid bolus and orders a CXR, ECG, and echocardiogram because of the concern for myocarditis. Non-invasive position pressure may be initiated. They initiate inotropic medication for cardiogenic shock. For advanced learners, the patient may progress to ventricular tachycardia requiring defibrillation. The team then discusses the case with cardiology and/or PICU and transfers the patient to the appropriate level of care. The parents are kept aware of medical decision making throughout the encounter.

Anticipated Management Mistakes

1. Failure to recognize cardiogenic shock vs septic shock: This may be expressed several ways. For example, the learners may only treat the patient with IV fluids and antibiotics. The faculty and standardized patient should be prompted to ask the learners “what else could be going on?” “Is there anything else you can do about the blood pressure?” “Can an infection really do all of this?”
2. Preoccupation with intubating the patient: Children with cardiogenic shock are at high risk for arrest during RSI due to decreased preload and cardiac output. This should only be performed emergently when loss of life is an imminent risk. Otherwise, the risk, benefits, and back-up plan should be discussed with a pediatric cardiologist first.