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Toxic myocarditis — Clinical Guidelines

Overview

Toxic myocarditis results from severe intoxication leading to myocardial injury and dysfunction, often complicating cases of systemic toxicity from various substances including diquat, hydrogen cyanamide, and diethylene glycol. 2 6 12

Diagnosis

Clinical presentation includes cardiogenic shock, arrhythmias, and signs of multiorgan dysfunction.

Laboratory findings may reveal elevated cardiac enzymes, electrolyte imbalances, and organ-specific dysfunction markers.

Imaging (echocardiography) can show myocardial dysfunction or structural abnormalities.

Toxicological screening of blood, urine, and gastric contents to identify the specific toxin is crucial. 1 4 13

Management

Stabilization: Airway management, ventilation support, and hemodynamic stabilization with intravenous fluids or vasopressors as needed. 17

Prevention of Absorption: Gastric lavage if ingestion is recent and safe to perform; consider activated charcoal for ongoing absorption prevention. 8 16

Enhanced Excretion: Renal replacement therapy (RRT) may be necessary for toxins not effectively cleared by conventional means, especially in severe cases. 5

Supportive Care: Management of arrhythmias, mechanical circulatory support (e.g., ECMO in refractory cases), and organ support systems as indicated. 1 14

Specific Antidotes: Use of specific antidotes if available (e.g., ascorbic acid for chromium poisoning). 14

Special Populations

Pediatrics: Special attention to the unique risks posed by household products and the importance of avoiding harmful interventions like improper gastric lavage. 3 7 11

Elderly: Increased susceptibility to multiorgan failure; close monitoring of organ function and tailored supportive care. 4

Comorbidities: Patients with pre-existing cardiac conditions may have worse outcomes; individualized management plans are essential. 1 17

Key Recommendations

Immediate Toxicological Screening: Conduct comprehensive toxicological screening of biological samples to identify the specific toxin and guide treatment. (Evidence: Strong 1 13)

Use of ECMO for Refractory Cases: Consider extracorporeal membrane oxygenation (ECMO) in patients with refractory cardiogenic shock or cardiac arrest due to toxic myocarditis. (Evidence: Moderate 1)

Supportive Renal Replacement Therapy: Implement renal replacement therapy when necessary to manage severe metabolic disturbances or toxin accumulation not amenable to conventional treatments. (Evidence: Moderate 5)

Avoid Harmful Interventions: In pediatric cases, strictly avoid improper gastric lavage techniques to prevent additional harm. (Evidence: Expert opinion 16)

Tailored Supportive Care: Provide individualized supportive care addressing arrhythmias, hemodynamic instability, and multiorgan dysfunction based on clinical presentation and laboratory findings. (Evidence: Moderate 17)

References

1 Maier S, Rösner L, Saemann L, Sogl J, Beyersdorf F, Trummer G et al.. Extracorporeal Membrane Oxygenation in Intoxication and Overdoses: A Systematic Review. The Thoracic and cardiovascular surgeon 2024. link 2 Ness-Cochinwala M, Proaño JS, Bernstein JN, Martinez P, Ladd H, Totapally B. A Case of a Lethal Diquat Ingestion in a Toddler. The Journal of emergency medicine 2022. link 3 Martínez-Sánchez L, López-Ávila J, Barasoain-Millán A, Angelats-Romero CM, Azkunaga-Santibañez B, Molina-Cabañero JC. [Actions that should not be taken with a paediatric patient who has been exposed to a potentially toxic substance]. Anales de pediatria 2021. link 4 Sharif AF, Fayed MM. Evaluation of Multiple Organ Dysfunction Score (MODS) and the Sequential Organ Failure Assessment (SOFA) score as in-hospital outcome predictors among cases of hydrogen cyanamide exposure: a cross-sectional study. Environmental science and pollution research international 2021. link 5 Raina R, Grewal MK, Blackford M, Symons JM, Somers MJG, Licht C et al.. Renal replacement therapy in the management of intoxications in children: recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) workgroup. Pediatric nephrology (Berlin, Germany) 2019. link 6 Wittschieber D, Heuberger K, Schulz R, Köhler H, Varchmin-Schultheiß K. Fatal poisoning with diethylene glycol in an unusual setting. Forensic science, medicine, and pathology 2019. link 7 O'Donnell KA. Pediatric Toxicology: Household Product Ingestions. Pediatric annals 2017. link 8 Schaper A, Ceschi A, Deters M, Kaiser G. Of pills, plants, and paraquat: the relevance of poison centers in emergency medicine. European journal of internal medicine 2013. link 9 Beuhler MC, Spiller HA, Sasser HC. The outcome of unintentional pediatric bupropion ingestions: a NPDS database review. Journal of medical toxicology : official journal of the American College of Medical Toxicology 2010. link 10 Curtis LA, Dolan TS, Seibert HE. Are one or two dangerous? Lidocaine and topical anesthetic exposures in children. The Journal of emergency medicine 2009. link 11 Michael JB, Sztajnkrycer MD. Deadly pediatric poisons: nine common agents that kill at low doses. Emergency medicine clinics of North America 2004. link 12 Eisinger M, Almog Y. Pyrimidifen intoxication. Annals of emergency medicine 2003. link 13 Hanzlick R. National Association of Medical Examiner's Pediatric Toxicology (PedTox) Registry. Toxicology 1996. link03245-b) 14 Meert KL, Ellis J, Aronow R, Perrin E. Acute ammonium dichromate poisoning. Annals of emergency medicine 1994. link70288-8) 15 Ariffin WA, Choo KE, Karnaneedi S. Cassava (ubi kayu) poisoning in children. The Medical journal of Malaysia 1992. link 16 Scalzo AJ, Tominack RL, Thompson MW. Malposition of pediatric gastric lavage tubes demonstrated radiographically. The Journal of emergency medicine 1992. link90142-g) 17 Barkin RM. Toxicologic emergencies. Pediatric annals 1990. link 18 Scalise JA, Harchelroad F, Dean BS, Krenzelok EP. Berry identification by emergency health care providers. Veterinary and human toxicology 1988. link 19 Rold JF. Mushroom madness. Psychoactive fungi and the risk of fatal poisoning. Postgraduate medicine 1986. link 20 Hayman J. Datura poisoning--the Angel's Trumpet. Pathology 1985. link 21 Liener IE. Natural toxins in plant foods. Nutrition and health 1984. link 22 Hepler BR, Sutheimer CA, Sunshine I. The role of the toxicology laboratory in emergency medicine.II: Study of an integrated approach. Journal of toxicology. Clinical toxicology 1984. link 23 Tynan RF, Fisher MM, Ibels LS. Self-poisoning with propranolol. The Medical journal of Australia 1981. link 24 Watling R. A panaeolus poisoning in Scotland. Mycopathologia 1977. link 25 Arthurs GJ, Wise CC, Coles GA. Poisoning by cresol. Anaesthesia 1977. link 26 Richardson SG, Giles C, Swan CH. Two cases of sodium azide poisoning by accidental ingestion of Isoton. Journal of clinical pathology 1975. link

Toxic myocarditis