Initial testing for of CHF includes CXR, EKG, and BNP Do not ignore mild cardiomegaly and increased pulmonary vascular markings on CXR EKG may show arrhythmia or changes consistent with myocarditis or cardiac ischemia BNP aids in differentiating CHF from lung disease and can be trended after initiation of treatment Echocardiogram is the definitive test to assess cardiac function but emergency ultrasound is increasingly used in pediatric EM to screen for abnormal left ventricular systolic function Additional evaluation is case dependent and geared toward suspected etiologies (i.e., CBC, thyroid function, metabolic evaluation, etc.) Management The priority is to restore hemodynamic stability To initiate proper therapy heart failure should be categorized ( Fig 86.12 ) Diuretics are the mainstay of management of CHF with volume overload Administration of diuretics should not be delayed in these patients Inotropic therapy, such as dopamine, epinephrine, norepinephrine, milrinone, or dobutamine may be necessary in patients with poor perfusion Milrinone therapy may be instituted if blood pressure is adequate Dopamine at to 20 μg/kg/min is appropriate in patients with poor perfusion Epinephrine and norepinephrine support blood pressure Milrinone or dobutamine are used in pulmonary hypertension Digoxin has fallen out of favor because of time needed to reach therapeutic levels and narrow therapeutic window and availability of better drugs now Afterload reduction therapy is beneficial in some cases Patients should be admitted and monitored in a critical care unit with continuous telemetry It is very important to record any arrhythmia that occurs in the ED Cardiology should be consulted early ACQUIRED HEART DISEASE Goals of Treatment The goal of the EM provider is the early recognition of acquired pediatric heart disease in the setting of vague, nonspecific symptoms This overview of acquired heart disease in pediatrics includes cardiomyopathies (hypertrophic, dilated, and restrictive), myocarditis, pericarditis/tamponade, endocarditis, acute rheumatic fever (ARF), Kawasaki disease (KD), and cardiac trauma