# Asymptomatic Pediatric SVT: Medicate or Wait?



## Fox800 (Nov 15, 2010)

8 year old male, was riding in the back seat of a car, blowing up a balloon when he told parents he felt his heart racing. Parents played it off, ten minutes later kiddo still has the same complaint. Parents checked pulse, found it to be super-fast, took kiddo to pediatrician, who called 911.

Child presents without complaints. No palpitations, no chest pain/SOB/ligthheadedness/near-syncope/dizziness/weakness. Vital signs stable (aside from an initial pulse of 212-220). Skin pink/warm/dry, good cap. refill, clear lung sounds, everything looks fine. No history/meds/allergies. 12-lead EKG shows a regular, narrow-complex rhythm that holds between 210-215. No response to vagal maneuvers (had kid blow through a straw, ice pack to face, bear down).

The child's palpitations had subsided before you arrived on scene. You are 10 minutes by ground to the children's hospital (comprehensive care). You've successfully established an IV in the child's AC.

Adenosine, or no?

I'll tell you guys what happened in a little bit.


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## MrBrown (Nov 15, 2010)

No not at all, asymptomatic arrythmia in the short term does not require treatment from the Ambo's anyway.  Take him to the hospital for further investigation where it will be decided by the people in white coats (who may or may not moonlight in orange jumpsuits) will decide if treatment is approprioate.


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## TacoMEDIC (Nov 15, 2010)

MrBrown said:


> No not at all, asymptomatic arrythmia in the short term does not require treatment from the Ambo's anyway.  Take him to the hospital for further investigation where it will be decided by the people in white coats (who may or may not moonlight in orange jumpsuits) will decide if treatment is approprioate.



exactly


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## MrBrown (Nov 16, 2010)

TacoMEDIC said:


> exactly



So where *exactly* is my taco man? Come on bro ....


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## fast65 (Nov 16, 2010)

MrBrown said:


> No not at all, asymptomatic arrythmia in the short term does not require treatment from the Ambo's anyway.  Take him to the hospital for further investigation where it will be decided by the people in white coats (who may or may not moonlight in orange jumpsuits) will decide if treatment is approprioate.



Agreed, I see no need for adenosine in an asymptomatic 8 yo


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## TacoMEDIC (Nov 16, 2010)

MrBrown said:


> So where *exactly* is my taco man? Come on bro ....



If Brown ever comes to Southern California, I'll buy him one


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## STXmedic (Nov 16, 2010)

MrBrown said:


> So where *exactly* is *my* taco man? Come on bro ....



Is this considered 4th person? 

I agree. As long as the child stays asymptomatic, I personally would not perform any prehospital intervention.


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## MrBrown (Nov 16, 2010)

*Brown slinks away, head held down in shame .....


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## Akulahawk (Nov 16, 2010)

Asymptomatic aside from the fast rate? In the pre-hospital setting, I'm very much inclined to simply observe and transport to a hospital that has a pediatric cardiologist or at least a cardiology unit that has some familiarity with peds. Kids can handle things like this far better than adults can. After all, from what I recall, their primary means of compensating for things is to stomp on the gas and kick up the heart rate.


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## Fox800 (Nov 16, 2010)

I did the same thing you guys did. Watched the kid, gave him a conservative amount of fluids to see if anything might change (didn't). Transported to the children's hospital, they converted him wtih adenosine within about 10 minutes of our arrival. A-OK.


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## 46Young (Nov 16, 2010)

Asymptomatic..... you just answered your own question. Why the fluids? You didn't mention that he was hypotensive (the pt would be unstable then, no?). There was no mention of volume loss due to malnutrition, vomiting/diarrhea, etc.


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## Akulahawk (Nov 16, 2010)

Had the kid been symptomatic/unstable... then sitting on my hands and simply observing would not be an option that I'd entertain for long.


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## Fox800 (Nov 16, 2010)

46Young said:


> Asymptomatic..... you just answered your own question. Why the fluids? You didn't mention that he was hypotensive (the pt would be unstable then, no?). There was no mention of volume loss due to malnutrition, vomiting/diarrhea, etc.



This call was a while back. Thinking back, I don't think I actually gave fluids. D'oh.


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## Veneficus (Nov 16, 2010)

Sounds like a great plan to me. 


Here is some food for thought, 

How would you have felt if you did give the kid adenosine, he converted, and the parents would have felt your efforts were enough and refused further treatment or transport?


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## EMSrush (Nov 16, 2010)

If he is asymptomatic, monitor carefully and transport.


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## LondonMedic (Nov 16, 2010)

Frankly, even if he is symptomatic, you're ten minutes away from a paediatric emergency department. What's the question again?


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## abckidsmom (Nov 16, 2010)

46Young said:


> Asymptomatic..... you just answered your own question. Why the fluids? You didn't mention that he was hypotensive (the pt would be unstable then, no?). There was no mention of volume loss due to malnutrition, vomiting/diarrhea, etc.



Kids stay dry.  Almost all kids drink only to thirst, especially with school days and asking permission to visit the water fountain, etc.  Thus, when there's an insult to normal, a fluid bolus appropriate to the child's weight is a fine idea, IMO.


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## abckidsmom (Nov 16, 2010)

LondonMedic said:


> Frankly, even if he is symptomatic, you're ten minutes away from a paediatric emergency department. What's the question again?



I would have treated symptomatic in a heartbeat (snicker ).  Why would we not?  If the heart rate is such that it's not perfusing the brain properly, why wait?

This rate wasn't exceptionally high, though.  I'm a chubby 30 something and I keep my heart rate in the 180s for 30 minutes when I work out.  For an 8 yo heart, I am not too bothered by a rate of 210 in the short term with no symptoms.


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## LondonMedic (Nov 16, 2010)

abckidsmom said:


> I would have treated symptomatic in a heartbeat (snicker ).  Why would we not?  If the heart rate is such that it's not perfusing the brain properly, why wait?


Because there's a difference between symptomatic, cerebral hypoperfusion and irreversible cerebral hypoperfusion.

There's also a big difference between you and a paediatric emergency physician or a paediatric cardiologist.


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## abckidsmom (Nov 16, 2010)

LondonMedic said:


> Because there's a difference between symptomatic, cerebral hypoperfusion and irreversible cerebral hypoperfusion.
> 
> There's also a big difference between you and a paediatric emergency physician or a paediatric cardiologist.



I get the difference between symptomatic, cerebral hypoperfusiona nd irreversible cerebral hypoperfusion.  In our over 1 hour transport times, these things matter.  We never have the luxury of making the decision "now, or 10 minutes from now by the ER."  

I respect your opinion on this, I'm just not clear.  What's different about adenosine administration by a pediatric physician than a paramedic?


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## 8jimi8 (Nov 16, 2010)

abckidsmom said:


> I get the difference between symptomatic, cerebral hypoperfusiona nd irreversible cerebral hypoperfusion.  In our over 1 hour transport times, these things matter.  We never have the luxury of making the decision "now, or 10 minutes from now by the ER."
> 
> I respect your opinion on this, I'm just not clear.  What's different about adenosine administration by a pediatric physician than a paramedic?



I think his implication is that the pediatric cardiologist, has enough education to take over when the pals algorithm moves to the "consult an expert" category.


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## Aidey (Nov 16, 2010)

abckidsmom said:


> I respect your opinion on this, I'm just not clear.  What's different about adenosine administration by a pediatric physician than a paramedic?




The pediatric physician can recognize WPW and the like.


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## gicts (Nov 16, 2010)

Were 12-leads done? Under his condition, I think the best course of action would to monitor and try to pick up a reason as to why there is SVT. Did he end up being a direct admit, or was he converted in the ER?


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## LondonMedic (Nov 16, 2010)

abckidsmom said:


> What's different about adenosine administration by a pediatric physician than a paramedic?


Absolutely nothing, it's just pushing a drug down an IV after all...

If you think a physicians blindly practice protocol driven medicine, I'd suggest that you remember that there is a significant difference between medicine and paramedicine.


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## abckidsmom (Nov 16, 2010)

LondonMedic said:


> Absolutely nothing, it's just pushing a drug down an IV after all...
> 
> If you think a physicians blindly practice protocol driven medicine, I'd suggest that you remember that there is a significant difference between medicine and paramedicine.




Come on.  

I'm really good at sarcasm too, but it really was a real question.  Can you talk a little about what the issues might be?


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## Outbac1 (Nov 16, 2010)

On my own with an asymptomatic pt, monitor and transport. However you were in a pediatricians office with lots of equipment and drugs. In the medical version of Rock, Paper, Scissors Dr. trumps Paramedic. What did the Dr. want done? I would have referred to the Dr. and followed their advice.


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## 46Young (Nov 16, 2010)

Veneficus said:


> Sounds like a great plan to me.
> 
> 
> Here is some food for thought,
> ...



Kind of similar to treating w/ ntg before obtaining a 12-lead. No evidence of STEMI will change the treatment course.


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## 46Young (Nov 16, 2010)

abckidsmom said:


> Kids stay dry.  Almost all kids drink only to thirst, especially with school days and asking permission to visit the water fountain, etc.  Thus, when there's an insult to normal, a fluid bolus appropriate to the child's weight is a fine idea, IMO.



I understand what you're saying, but there was no stated indication for fluid therapy. The pt wasn't in sinus tach, there was no hx suggestive of hypovolemia, the pt wasn't hypotensive, nor was the pt in cardiogenic shock that would benefit from increased preload. That's what I was getting at. To follow your logic, we would be giving most sick children presumptive fluid boluses by default. I prefer not to medicate unless indicated.


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## 18G (Nov 16, 2010)

abckidsmom... your thinking is right on.... arrogance is just rearing its ugly head again. A child in SVT with a rate over 220 that is showing signs of hemodynamic compromise needs treated right then and there. Adenosine is a drug with a great safety profile. Why let a poor child suffer and feel crappy for ten minutes and possibly deteriorate. 

If anyone is unsure about giving adenosine than CONSULT ON THE RADIO OR BY PHONE WITH THE PEDIATRIC CENTER OR OTHER RECEIVING HOSPITAL AND GET ORDERS FROM A PHYSICIAN. I would have asked the pediatrician what his thoughts and opinions were regarding adenosine as well.


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## 18G (Nov 16, 2010)

.... on a side note....

so anytime we as EMS encounter a sick kid were not supposed to treat them because were not pediatricians, pediatric cardiologist, or the like?


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## LondonMedic (Nov 16, 2010)

18G said:


> abckidsmom... your thinking is right on.... arrogance is just rearing its ugly head again. A child in SVT with a rate over 220 that is showing signs of hemodynamic compromise needs treated right then and there. Adenosine is a drug with a great safety profile. Why let a poor child suffer and feel crappy for ten minutes and possibly deteriorate.


In what way is the asymptomatic child in this scenario showing signs of heamodynamic compromise? Why does it need to be treated 'right then and there'?




18G said:


> so anytime we as EMS encounter a sick kid were not supposed to treat them because were not pediatricians, pediatric cardiologist, or the like?


Anytime you encounter any patient who does not need immediate stabilisation, there are several good arguments for transporting them and not :censored::censored::censored::censored:ing around on scene.

Maybe it is arrogance; yours if you think that a paramedic can do medicine better than a hospital.


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## 46Young (Nov 16, 2010)

LondonMedic said:


> Absolutely nothing, it's just pushing a drug down an IV after all...
> 
> If you think a physicians blindly practice protocol driven medicine, I'd suggest that you remember that there is a significant difference between medicine and paramedicine.



If an intervention is indicated (key word indicated), then it's  negigent to not perform that intervention. Explain to me how it's legally defensible, and also acceptable prehospital pt care to withhold indicated medications.


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## abckidsmom (Nov 16, 2010)

LondonMedic said:


> In what way is the asymptomatic child in this scenario showing signs of heamodynamic compromise? Why does it need to be treated 'right then and there'?
> 
> Maybe it is arrogance; yours if you think that a paramedic can do medicine better than a hospital.



I think the conversation had moved on to the hypothetical unstable kid who was 10 minutes from the ER.  If you were able to calm down enough to address the questions instead of getting wrapped up in emotion, we could learn your unique point of view.


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## 8jimi8 (Nov 16, 2010)

18G said:


> .... on a side note....
> 
> so anytime we as EMS encounter a sick kid were not supposed to treat them because were not pediatricians, pediatric cardiologist, or the like?



You are stacking inferences. No one said that.  The original question was what would you have done with the Asymptomatic Pedi SVT.  I think everyone agreed that waiting to treat was the right decision.  Symptomatic is another story and no one said to withhold tx in that situation.  Yes we are all eager to hear LondonMedics reply, tho there may not be one.  But you don have to shout us down... We are all on the same page.


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## LondonMedic (Nov 16, 2010)

46Young said:


> If an intervention is indicated (key word indicated), then it's  negigent to not perform that intervention. Explain to me how it's legally defensible, and also acceptable prehospital pt care to withhold indicated medications.


It's also negligent to delay transport because you think you know what's indicated.

:censored::censored::censored::censored:ing hell, if I had a quid for every sick patient that I've seen blued in with scene times of over an hour, I'd be buying more beer than I am now.


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## 46Young (Nov 16, 2010)

LondonMedic said:


> In what way is the asymptomatic child in this scenario showing signs of heamodynamic compromise? Why does it need to be treated 'right then and there'?
> 
> 
> Anytime you encounter any patient who does not need immediate stabilisation, there are several good arguments for transporting them and not :censored::censored::censored::censored:ing around on scene.
> ...



Not arrogance, but rather what we've been educated and trained to do. Doing our jobs. Furthermore, our protocols and guidelines dictate what and where we are to do these interventions. For example, NYC's protocols generally advise txp early on, and to do these interventions enroute to the ED. Not withhold treatments, but to not delay txp to do so.

http://www.nycremsco.org/images/articlesserver/ALS_Protocols_January_2010_v01012010d.pdf


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## usalsfyre (Nov 16, 2010)

46Young said:


> If an intervention is indicated (key word indicated), then it's  negigent to not perform that intervention. Explain to me how it's legally defensible, and also acceptable prehospital pt care to withhold indicated medications.



I call BS. Part of being a competent clinician is having the discretion to not to perform specific interventions. It's done daily with regards to surgeries, meds for chronic conditions, ect.


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## abckidsmom (Nov 16, 2010)

usalsfyre said:


> I call BS. Part of being a competent clinician is having the discretion to not to perform specific interventions. It's done daily with regards to surgeries, meds for chronic conditions, ect.



I can agree with this.  "Indicated" can include a gray area where a competent provider may or may not decide to intervene.  There is a medic I really respect who tends toward doing every. single. intervention he can for every patient he interacts with.  Me?  Not so much.  

This is why the protocol book is more of a set of guidelines, not a Bible that must be adhered to.  

(sneaky religious reference )


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## 18G (Nov 16, 2010)

LondonMedic said:


> In what way is the asymptomatic child in this scenario showing signs of heamodynamic compromise? Why does it need to be treated 'right then and there'?



I was referring to the scenario of this child (or any child) becoming unstable as was mentioned in the flow of conversation. I assume you recommend we allow adult patients with symptomatic SVT or VT remain in those rhythms because we are not physicians and "do not understand" and cannot "do medicine as well as a hospital"?



LondonMedic said:


> Anytime you encounter any patient who does not need immediate stabilisation, there are several good arguments for transporting them and not ing around on scene.



Of course. And this is a principle that we have ingrained in us and embrace from a very early stage as EMS providers. Nobody said anything about messing around onscene. It doesn't take all that long to start a line and give a med onscene or do it enroute. 



LondonMedic said:


> It's also negligent to delay transport because you think you know what's indicated.



So Paramedics have no idea when treatments are indicated? We just blindly go around giving medicine and doing interventions without having a clue as to their indication? Really? No one is claiming to know everything or is asserting that Paramedics know as much as doctors. But we are more than capable of assessing a patient and knowing when something is indicated or not. To the accuracy of a physician? Of course not... that's why we consult with a physician from the field. However, it has been found that some Paramedics have 12-Lead skills that rival those of many physicians. 

If a patient is presenting with a condition and meets criteria of a written medical protocol, you better have very good reason as to why you didn't follow it. There are few circumstances when an EMS provider should deviate from written medical protocol. 

Having an unstable child in SVT and withholding treatment because your not a pediatric cardiologist and your only ten minutes away from a hospital is not a defense I would want to use in a case of negligence for withholding treatment. If it were my child and you did this, it would ring out to me that you were clueless and scared to treat my kid and wanted to take the easy way out. You better never let my kid suffer based on this irrationality. YOU DO NOT HAVE TO BE A PEDIATRIC CARDIOLOGIST TO GIVE ADENSOSINE!

I wholeheartedly agree that part of being a good practitioner is knowing when not to act or perform a skill, but when it is clearly indicated lets just do our jobs.


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## Aidey (Nov 16, 2010)

I'm repeating myself to prove a point.



Aidey said:


> The pediatric physician can recognize WPW and the like.



WPW et al. first present most commonly under the age of 25. If I have someone under 25 in SVT who is stable, I am not giving them adenosine until I am confident beyond a doubt that it is a non WPW case. If they are unstable, well, why the heck are we using adenosine and not electricity? 

As far as my doctor is concerned our protocols are guidelines. If I bring in a stable patient in SVT I'm going to have very little, if any, explaining to do.


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## Aidey (Nov 16, 2010)

18G said:


> So Paramedics have no idea when treatments are indicated? We just blindly go around giving medicine and doing interventions without having a clue as to their indication? Really? No one is claiming to know everything or is asserting that Paramedics know as much as doctors. But we are more than capable of assessing a patient and knowing when something is indicated or not.



Some are, some are not. True story. 16 year old gets hit in the chest with a base ball, and is complaining of chest pain. Medic gave him nitro and aspirin for his "chest pain". Medic still is practicing. Here is another one, medic gives Bicarb for a trazodone OD without confirming it is a tricyclic (it is a tetracyclic), and ignoring the fact the pt had none of the indications to give it.

Edit - One more case, on topic. Ambulance crew arrives on scene to find the 20 something year old female patient RUNNING AWAY from the Fire Medic who was INSISTING that she needed adeosine, even after she explained to him that she had WPW and couldn't have it.


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## WTEngel (Nov 16, 2010)

*Fluid boluses and "asymptomatic" peds...*

We all know kids can compensate extremely well for a certain amount of time...so a blood pressure in "normal" or "low normal" range does not necessarily ensure that hemodynamic compromise is not present. Without knowing what the SVR is (which you will never know in the field, and most likely not in a primary care pediatricians office) then we can't really tell what type of vascular compensation the kiddo is under.

So, with all that in mind, a 10-20 cc/kg bolus in just about any sick child is never a bad idea. I say this from 3 years of critical care peds transport working with extremely sick kids. I don't claim to be a pedi intensivist by any means, however, I would be surprised to find a pedi ER doc, intensivist, or cardiologist who did not agree...

I do agree with the treatment under the given circumstances. SVT without any quantitative or qualitative signs of hemodynamic compromise, start an IV (I have seen this convert a number of kids in and of itself) try some basic vagal maneuvers, and monitor VERY closely. Expect that they will crash, because like I said earlier, kids compensate very well for only so long, and when they crash, it is nearly instantly.


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## Veneficus (Nov 16, 2010)

WTEngel said:


> We all know kids can compensate extremely well for a certain amount of time...so a blood pressure in "normal" or "low normal" range does not necessarily ensure that hemodynamic compromise is not present. Without knowing what the SVR is (which you will never know in the field, and most likely not in a primary care pediatricians office) then we can't really tell what type of vascular compensation the kiddo is under.
> 
> So, with all that in mind, a 10-20 cc/kg bolus in just about any sick child is never a bad idea. I say this from 3 years of critical care peds transport working with extremely sick kids. I don't claim to be a pedi intensivist by any means, however, I would be surprised to find a pedi ER doc, intensivist, or cardiologist who did not agree...
> 
> I do agree with the treatment under the given circumstances. SVT without any quantitative or qualitative signs of hemodynamic compromise, start an IV (I have seen this convert a number of kids in and of itself) try some basic vagal maneuvers, and monitor VERY closely. Expect that they will crash, because like I said earlier, kids compensate very well for only so long, and when they crash, it is nearly instantly.




Strong post.

If I could I would just like to add that kids often "look fine" when they are indeed compensating, so always keep a high index of suspicion. 

I have also seen many who transiently respond to treatment. So if they do "look better, get better," or whatever definately try to transport them as soon as possible and be very aware they can outright crash even after what looks like successful resus in a heartbeat.


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## Akulahawk (Nov 16, 2010)

As others have indicated, had this kid become unstable, then I'd begin intervening. If I thought the kid might be trending towards unstable and my protocols guide me towards the "sit on hands until unstable" treatment option, I'd be on the radio or the phone to my OLMC to get an order to take care of business. In the case of Sacramento, since adenosine is NOT in the protocol for pediatric SVT, I'd have to get a base order to sedate/synch cardiovert. (It's actually NOT an approved med, period.) In the OP's case, in Sacramento, a Valsalva maneuver is indicated, along with transport. 

I suspect that our protocols are set up that way because peds can handle high heart rates better than adults can and unless you're in a rural area, an ED is typically < 20 min away, if not closer. Since most of the County's residents are in an urban/suburban area, an ED will typically be about 10 min away.

At least our Protocols do tell us to make base contact for situations that aren't within the guidelines or that show a need to go beyond them.


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## Akulahawk (Nov 16, 2010)

WTEngel said:


> We all know kids can compensate extremely well for a certain amount of time...so a blood pressure in "normal" or "low normal" range does not necessarily ensure that hemodynamic compromise is not present. Without knowing what the SVR is (which you will never know in the field, and most likely not in a primary care pediatricians office) then we can't really tell what type of vascular compensation the kiddo is under.
> 
> So, with all that in mind, a 10-20 cc/kg bolus in just about any sick child is never a bad idea. I say this from 3 years of critical care peds transport working with extremely sick kids. I don't claim to be a pedi intensivist by any means, however, I would be surprised to find a pedi ER doc, intensivist, or cardiologist who did not agree...
> 
> I do agree with the treatment under the given circumstances. *SVT without any quantitative or qualitative signs of hemodynamic compromise, start an IV (I have seen this convert a number of kids in and of itself) try some basic vagal maneuvers, and monitor VERY closely*. Expect that they will crash, because like I said earlier, *kids compensate very well for only so long, and when they crash, it is nearly instantly.*


That's pretty much my train of thought with peds... and pretty much is what my County wants us to do with "stable" kids with SVT.


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## JAXMEDIC1 (Nov 16, 2010)

Prevent medicine is good medicine..NO MORE FREAKIN BALLOONS!!!LOL

Seriously though,in my opinion you did everything spot on to include "IV MAINT"..SVT is very common in PEDS and is rarely life threatening,but we must always act as the advocate of our patients.


               "Some people watch beer commercials while others live them"

                                                FIRE LIFE


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## MrBrown (Nov 16, 2010)

Where are these guys when you need them?


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## usalsfyre (Nov 16, 2010)

There is precious little I do anymore simply to satisfy "protocol". I treat based on what I think is indicated/will lead to the best outcome for the patient. If I don't feel as though an intervention will be paticularly helpful, I omit it. If a different med/intervention not in a paticular guideline will be helpful, I'm on the phone for an order. In extreme cases I'll go ahead and perform the intervention and doccument why I couldn't get a hold of med control. If this makes me a cowboy in your eyes than so be it, the important people (my medical director and clinical education staff) expect this from me.

Of course this also requires a strong understanding of pharmacology, pathophysiology, anatomy, ect.


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## 46Young (Nov 16, 2010)

usalsfyre said:


> I call BS. Part of being a competent clinician is having the discretion to not to perform specific interventions. It's done daily with regards to surgeries, meds for chronic conditions, ect.



I'm not advocating emptying the drug box just because you can. Actually, I've advised against it on other threads. When I say "indicated," I mean that the pt will benefit from the treatment, not something the medic thinks they should include just because the protocol says to. Lasix for every APE pt, or a D50 bolus for every hypoglycemic would be two such examples. NTG for costochondritis or pain when coughing from a pt w/ the flu would be another case. I thought that discretion was implied. I'm talking about withholding interventions that should help the pt. If I were to defer that treatment, for whatever reason, and the pt suffers harm or death, there goes my job, card, and house.

I've withheld interventions from time to time. For example, I had an elderly pt w/ symptomatic bradycardia, showing an idioventricular rhythm of 20. It was a while ago, but the BP was around 98/50 semi-fowler's (c/o dyspnea when supine), radial pulse wasn't thready, the pt was oriented and quick to respond, skin was a little pale, but not terribly so. So long as the pt didn't exert themselves, they were able to maintain. I could have paced, or given atropine (it obviously wouldn't have done anything), but I decided to only do a 12, O2 NC, IV, place the pads to be ready to pace, and I also had versed drawn up and ready, and my arrest meds/ETI equipment handy as well.


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## 46Young (Nov 16, 2010)

LondonMedic said:


> It's also negligent to delay transport because you think you know what's indicated.
> 
> :censored::censored::censored::censored:ing hell, if I had a quid for every sick patient that I've seen blued in with scene times of over an hour, I'd be buying more beer than I am now.



I know that a paramedic's level of education is far from that of a doctor, but we're expected to know what's indicated what's not. We would just carry  the old air and chair and not much else if this wasn't the case. The presence of pediatric protocols and guidelines demand that we use them if indicated. Otherwise, every case would be load and go w/ supportive measures only. If we see something that can be corrected to some extent in the field, then we're going to do it. This typically happens enroute to the hospital in most cases. No one's delaying txp here, but we're not going to set up the monitor, drop a lock and stare at the pt all the way to the hospital when our interventions can be of benefit.


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## SoCal (Nov 19, 2010)

18G said:


> .... on a side note....
> 
> so anytime we as EMS encounter a sick kid were not supposed to treat them because were not pediatricians, pediatric cardiologist, or the like?



^ Best post in the whole thread. 

We have been given the tools to solve problems and the education to back them up. If it is broke (even stable SVT in my protocols) then fix it with what you have in the box. If you are unsure of your knowledge/protocols then consult with the ER Dr. at the receiving hospital. 

The OP stated the pt. had received a 12 lead with confirmed SVT, so fix it, and transport him to the hospital where you can deliver the kid (fixed now) and the 12-lead and if they have any ?'s they can call the Dr. office he came from and even get the 12-lead from them as well.

This isn't a hard call and I am surprised how many medics on this site advocating acting so timidly. It backs up the knowledge that so many medics are scared of Peds. Kind of sad really....


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## Fox800 (Nov 19, 2010)

SoCal said:


> ^ Best post in the whole thread.
> 
> We have been given the tools to solve problems and the education to back them up. If it is broke (even stable SVT in my protocols) then fix it with what you have in the box. If you are unsure of your knowledge/protocols then consult with the ER Dr. at the receiving hospital.
> 
> ...



Interesting. This is the first vote for "medicate" after six pages of discussion.


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## abckidsmom (Nov 19, 2010)

SoCal said:


> ^ Best post in the whole thread.
> 
> We have been given the tools to solve problems and the education to back them up. If it is broke (even stable SVT in my protocols) then fix it with what you have in the box. If you are unsure of your knowledge/protocols then consult with the ER Dr. at the receiving hospital.
> 
> ...



I disagree with this.  While I am frustrated with the common phenomenon of medics being afraid of calls that involve kids, I believe that this is a circumstance where 10 minutes of caution with a stable patient is worth the trouble. 

Knowing how randomly protocols are written and approved, I'm much less likely to apply a blanket protocol than my assessment of the situation and the risks and benefits specific to the patient I see before me.  

What are the specific risks of adenosine administration for the 8 year old with stable tachycardia?  What are the specific benefits of adenosine administration for the 8 year old with stable tachycardia?

How do those risks and benefits change when you consider a 10 minute transport time?  1 hour transport time?

How do those risks and benefits change when you consider the patient being slightly unstable (skin pale or mottled, slight dyspnea, slight hypotension)?  How do they change when you consider the patient being profoundly unstable?

This is how the decision making process should go.  Not, "I have a protocol for that so let me use it."  More like, "There's a protocol for this, is it the best decision for this particular patient for me to go down that pathway?"


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## Veneficus (Nov 19, 2010)

SoCal said:


> ^ Best post in the whole thread.



I thought it was a good post too. While I was trying to diplomatically reach a consensus behind the scenes. My opinion is very much in line with ABC on this one.




SoCal said:


> We have been given the tools to solve problems and the education to back them up.



I think you are 50% right on this.

You have the tools to fix a problem, certainly not the education to back them up if you received a US paramedic education.



SoCal said:


> If it is broke (even stable SVT in my protocols) then fix it with what you have in the box..



Really? 

Now I will admit that most kids who wind up with PSVT, will self resolve even if you don't do anything, and they may never have another episode again. 

So if it fixes itself is it broke?

Let's consider for a minute:

Because of the normal development of the heart, all children have accessory conduction pathways. These pathways eventually fibrose as we become adults. Even in the cardiology community, there is no consensus as to when this actually happens, but the belief from the cardiologists who specialize at electrophysiology around here, the magic numbers are 13-14 for females and 15-16 for males. What if this kid was in SVT becase of an accessory conduction pathway?

No doubt any US paramedic can recite the ACLS guidlines, and certainly their local protocol. In the best interest of the patient this time, let the doctors (aka electrophysiology specializing cardiologists) have a look at what is going on so they can determine if a more invasive measure or no measure at all, would be a wise choice for a long term fix. 

You have nothing more invasive, but yo do have "use nothing" in the tool box.

Sure cardio can restimulate it, but if the kid is stable, and relatively unsymptomatic, then it doesn't have to be reproduced, which means the child will only have to go through it once.



SoCal said:


> If you are unsure of your knowledge/protocols then consult with the ER Dr. at the receiving hospital.



I am very aware of the scope and guidlines I work under, For years I taught paramedics their knowledge and I still teach to more educated providers. I have years of experience working in a level I peds trauma center which also had on staff at all times pediatricians subspecializing in peds emergencies. The first surgery I ever assisted in was an emergent nephrectomy on an 8 year old. I can tell you the difference in essential amino acid metabolism between kids and adults, as well as the physical development characteristics as they have evolved through the evolution of homosapien. I am comfortable with patients of any age. I have also had a few years of education to boot. 

Do you think the ER docs instantly initiate treatment on stable patients who are better served by a cardiologist or Peds cardiologist? (or any other specialty for that matter?)

Do you think they use more discretion on when that is?

Let's face it, not everyone in SVT is an emergency, the latest numbers I have heard is ~20% are emergent. With a confounder of a small percentage of people who die from SCD attributed as well. (but not as many peds who are attributed to long QT)

Every ED doc I have ever met who felt a patient was better cared for by another service referred the patient to them instead of opening up his box anymore than he absoltely had to in order to make sure they got to that specialist.

The reason we have peds EDs and what seems like a lot of peds transport teams is because they have better outcomes when served by specialists. (the cliche is kids are not small adults) They are actually more similar to the pupa stage of insects. See those university biology classes do make a difference in medicine.

We know EMS is not very efficent at saving lives. The best thing current US EMS can do for any patient is set them up for success by knowing what the next few links in the chain are and preparing patients for that.

Our friends in the rest of the modern world have better educated and equipped EMS providers to not always "fix" things, but to also recognize where and what type of care best serves patients. Thier education allows them to be both more knowledgable and therfore more comfortable than reciting protocols they had to memorize. 



SoCal said:


> The OP stated the pt. had received a 12 lead with confirmed SVT,



Devil's advocate:

It was confirmed SVT and not a narrow complex ventricular tachycardia? Because they figured it out or the machine didn't tell them?

(did you learn in paramedic class sometimes you can have a narrow QRS of ventricular origin?) 

Let me give you the benefit of the doubt. Let's say your protocols allow you to attempt a vagal maneuver, give 2 does of adensosine. (PALS recommendation for PEDS) and then cardiovert.

What if you gave this stable/unsymptomatic kid the adenosine and he didn't convert? Were you planning at that point to electively sedate and cardiovert him in the back of a rig?

If you felt cardioversion could wait a few minutes, why couldn't the adenosine?

What if the adenosine made him worse?  



SoCal said:


> so fix it, and transport him to the hospital where you can deliver the kid (fixed now) and the 12-lead and if they have any ?'s they can call the Dr. office he came from and even get the 12-lead from them as well.,



The chief of cardiology where I did my cardio rotation said to me when speaking of treatment modalities, "If there is a mechanical defect, than the treatment is to mechanically fix it. If the treatment is otherwise medical in nature, then medications are the way to treat it. Do not try to treat mechanical defects with medicines, it simply won't work and delays the proper treatment."

So if this kid is indicated for ablative therapy. (surgical in nature) How do you plan to "fix" this kid's mechanical defect in the back of your rig and do anything but delay proper treatment?



SoCal said:


> This isn't a hard call



I think we agree on this. But for different reasons. Stable/unsymptomatic, do nothing and let the people who specialize in it do the voodoo that they do best. 



SoCal said:


> and I am surprised how many medics on this site advocating acting so timidly.



Discretion is sometimes the better part of valor.

I do not see my support of not giving adenosine in this particular case as timid. I see it as knowing the best thing to do for the patient. Because I have some insight in to what could be wrong past an elementary discussion of it, as well as know what comes later down the line and think it is in the patient's best interest not to delay that care or provide a medication that will may not help or even be needed to begin with because most SVTs in kids self resolve. 

I don't have to prove to anyone I am not afraid to follow a cookbook. 



SoCal said:


> It backs up the knowledge that so many medics are scared of Peds. Kind of sad really....



I still have a valid paramedic cert in 2 states, so I am still a medic. I am not afraid of peds or any other patient. 

I agree many people are. But the majority opinions I have seen here, even though they differ slightly, are based from sound clinical judgement, not fear.

If the scenario was different and the kid was grossly symptomatic, the benefit of immediate decisive action would in my mind outweigh any delay in treatment. But I would initiate that treatment fully prepared to cardiovert if something didn't work or went wrong.

If the kid was grossly unstable, I would cardiovert right away.

But there is no indication of either. So I again advocate to initiate supportive care and watch and wait for the 10 minutes it would take to transport. Not because I am afraid to act, but because I have a little knowledge/insight on what may be best.


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## Akulahawk (Nov 19, 2010)

abckidsmom said:


> I disagree with this.  While I am frustrated with the common phenomenon of medics being afraid of calls that involve kids, I believe that this is a circumstance where 10 minutes of caution with a stable patient is worth the trouble.
> 
> Knowing how randomly protocols are written and approved, I'm much less likely to apply a blanket protocol than my assessment of the situation and the risks and benefits specific to the patient I see before me.
> 
> ...


That's all fine, well, and good... if you have adenosine handy. My county removed (or never approved in the first place) adenosine. For SVT, our only option is to sedate (if possible) and synch. cardiovert. In fact, last I checked, Sacramento doesn't allow anything BUT electricity for breaking unstable tachycardias...


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## Akulahawk (Nov 19, 2010)

Veneficus said:


> I thought it was a good post too. While I was trying to diplomatically reach a consensus behind the scenes. My opinion is very much in line with ABC on this one.
> 
> 
> 
> ...


Great discussion (and reminders about cardiology...) Thanks!!!


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## abckidsmom (Nov 19, 2010)

Akulahawk said:


> That's all fine, well, and good... if you have adenosine handy. My county removed (or never approved in the first place) adenosine. For SVT, our only option is to sedate (if possible) and synch. cardiovert. In fact, last I checked, Sacramento doesn't allow anything BUT electricity for breaking unstable tachycardias...



Edit:  Sorry about that.  For some reason I thought you and SoCal were the same poster.  My apologies for this snark.


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## Veneficus (Nov 19, 2010)

"there is no consensus as to when this actually happens, but the belief from the cardiologists who specialize at electrophysiology around here, the magic numbers are 13-14 for females and 15-16 for males. What if this kid was in SVT becase of an accessory conduction pathway?"

"Funny that's shortly after the typical onset of puberty... and about the same time when humans start being able increase cardiac output via stroke volume and not just heart rate..."


I agree more with the stroke volume.

Typical onset of puberty in the western world is now at 9-11y/o for females and 11-13 for males. As humans work of survival levels decrease, the earlier the onset of reproductive capacity.

Modern convieniences like grocery stores, family support, and inactive lifestyles are wonderful things, but not without side effects.


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## Akulahawk (Nov 19, 2010)

Veneficus said:


> "there is no consensus as to when this actually happens, but the belief from the cardiologists who specialize at electrophysiology around here, the magic numbers are 13-14 for females and 15-16 for males. What if this kid was in SVT becase of an accessory conduction pathway?"
> 
> "Funny that's shortly after the typical onset of puberty... and about the same time when humans start being able increase cardiac output via stroke volume and not just heart rate..."
> 
> ...


So very true!


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## Akulahawk (Nov 19, 2010)

abckidsmom said:


> Edit:  Sorry about that.  For some reason I thought you and SoCal were the same poster.  My apologies for this snark.


Not to worry... I evidently must have missed it.


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## 18G (Nov 19, 2010)

Even in the ED, how long are they gonna wait before they try a trial of adenosine? Chances are the ED will be pretty quick to try adenosine soon after arrival. The kid may be stable but I'm sure he/she probably feels kinda funny and not so good from having such a fast rate.  

If we go head with the adenosine prior to arrival at the ED, we can one... slow the rate and fix the problem, make the kid and parents feel better.... or two.... realize the adenosine isn't working so as soon as we arrive we can relate to the ED staff that the adenosine didn't work and the ED can go to an alternate therapy or just wait it out.... hence saving time. 

If i'm missing something about the safety profile of adenosine in kids someone please fill in the blanks for me.


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## Veneficus (Nov 19, 2010)

18G said:


> Even in the ED, how long are they gonna wait before they try a trial of adenosine? Chances are the ED will be pretty quick to try adenosine soon after arrival. The kid may be stable but I'm sure he/she probably feels kinda funny and not so good from having such a fast rate.



I think the answer to this depends on what hospital you are at. If cardiology is readily available I don't think the ED is going to be overly quick on the trigger. If it is one of those community hospitals then they will probably follow into the ACLS cookbook and push it.

The thing is are you deciding to play around with some treatments you like or are you really serious about breaking the arrythmia? 

In other words are you playing around, or really trying to help? 



18G said:


> If we go head with the adenosine prior to arrival at the ED, we can one... slow the rate and fix the problem, make the kid and parents feel better.... or two.... realize the adenosine isn't working so as soon as we arrive we can relate to the ED staff that the adenosine didn't work and the ED can go to an alternate therapy or just wait it out.... hence saving time.



Saving time is not an indication for adenosine nor is it the purpose of EMS intervention.

If the adenosine doesn't work, how far are you willing to go in your treatment?

The ED is not definitive therapy. You don't see PCI or any number of treatments or dx performed there. Many times simply because they are not equipped.

The patient in the scenario is stable, with minimal symptoms/complaints. This is not an emergency. If I was going to take it upon myself to do something, it would be in the best interest of the patient, not because I could.



18G said:


> If i'm missing something about the safety profile of adenosine in kids someone please fill in the blanks for me.



Reported side effects include. (from my pharm quick reference guide) 

Obviously it doesn't list the incidence of the side effects, but on the risk/benefit analysis, I would rather deal with the potential problems of this in a hospital in about 10 minutes than in the back of a truck because I could push the drug.

Cardiovascular
Facial flushing, headache, sweating, palpitations, chest pain,
hypotension, prolonged asystole, ventricular tachycardia, ventricular fibrillation, transient increase in blood pressure, bradycardia, atrial fibrillation, and Torsade de Pointes.

Respiratory
Bronchospasm, shortness of breath/dyspnea, chest pressure, hyperventilation, head pressure.


Central Nervous System
Seizure activity, including tonic clonic (grand mal) seizures, and loss of consciousness, lightheadedness, dizziness, tingling in arms, numbness, apprehension, blurred vision, burning sensation, heaviness in arms, neck and back pain

Gastrointestinal
Nausea, metallic taste, tightness in throat, pressure in groin.


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## 18G (Nov 19, 2010)

Perhaps I should have said, "increasing efficiency" instead of "saving time" although still somewhat synonymous. I agree the kid is not a critical patient where time is of the essence. But anytime we can increase efficiency and perhaps have a quicker resolution of someones problem... that is generally observed as a good thing. 

I'm playing off both sides for sake of discussion and don't think either sides approach would have been wrong.


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## Veneficus (Nov 19, 2010)

18G said:


> Perhaps I should have said, "increasing efficiency" instead of "saving time" although still somewhat synonymous.



But if they have to admit the kid for days, put him on a halter monitor, or induce an arrhythmia to diagnose whether the kid is a risk for SCD it doesn't save time or money compared to looking at him and the current EKG when he comes in. 

Especially since his first EKG to compare is most likely the one EMS did in the field.


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## Melclin (Nov 20, 2010)

1. Pick the kid up by the legs and dunk their head in a bucket of ice water. 

2. *Guitar solo*

3. ?????

4. Profit.


B)


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## SoCal (Nov 20, 2010)

18G said:


> Even in the ED, how long are they gonna wait before they try a trial of adenosine? Chances are the ED will be pretty quick to try adenosine soon after arrival. The kid may be stable but I'm sure he/she probably feels kinda funny and not so good from having such a fast rate.
> 
> If we go head with the adenosine prior to arrival at the ED, we can one... slow the rate and fix the problem, make the kid and parents feel better.... or two.... realize the adenosine isn't working so as soon as we arrive we can relate to the ED staff that the adenosine didn't work and the ED can go to an alternate therapy or just wait it out.... hence saving time.
> 
> If i'm missing something about the safety profile of adenosine in kids someone please fill in the blanks for me.



Another great post 18,

If there wasn't a funny feeling in this kids chest then he wouldn't have said anything to his parents and they wouldn't have taken him in. He didn't just take his pulse and say wow, 212, I should go tell my mom because that is outside my normal range. This kid is feeling symptoms, palpitations or otherwise.

Fix what you can, and honestly I feel like I got a complete paramedic education and to which I keep adding to by taking classes and following up on my pts. constantly learning, thanks for being concerned about my education though. 

And by your guys' argument, if he does go into a rare dysrhythmia then you are only 10 min away from the hospital and it will be fixed like all of you are looking for the hospital to fix it anyways. 

Once again I am just baffled reading some posts on this thread.


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## WTEngel (Nov 20, 2010)

*Have you fixed the problem?*

The idea of pushing adenosine to "fix the problem" is a bit short sighted in my opinion.

First off, as others have stated, if you get no conversion with the adenosine, why stop there? Why not cardiovert? In for a penny, in for a pound, right? I don't see any reason why adenosine should be taken lighter than cardioversion. You are introducing a medication into the patient's body that will cause there heart to stop for a matter of seconds. Probably doesn't hurt as much as cardioversion, but still shouldn't be taken any more lightly. 

Second, we must always remind ourselves to treat our patients, not the monitors to which they are attached. So, we have no hemodynamic compromise, patient is appropriately oriented, the only thing wrong at this point is a very squiggly line on a monitor that we simply don't like. We gain nothing by making that line a little less squiggly. The risk to benefit ratio just doesn't measure up in my mind. 

Last, I would like to point out that in my experience (3 years working solely in critical care peds in addition to another 4 working 911 and flight) most of these cases will do one of two things: A, they self convert. This is ideal... B, they will become symptomatic. This really sucks, but those of you itching to fix something now have something to fix! Giving adenosine to a non symptomatic patient and causing them to develop symptoms leading to you cardioverting is never a good feeling...so don't go there. Allow the patient to self convert while en route to the hospital (highly likely) or closely monitor and prepare to act if symptoms develop.

Some people in this thread might not agree, but I stand by my original statement that you would be hard pressed to find a peds intensivist or cardio doc who would disagree.


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## SoCal (Nov 20, 2010)

WTEngel said:


> Last, I would like to point out that in my experience (3 years working solely in critical care peds in addition to another 4 working 911 and flight) *most of these cases will do one of two things: A, they self convert. This is ideal... B, they will become symptomatic. *This really sucks, but those of you itching to fix something now have something to fix! Giving adenosine to a non symptomatic patient and causing them to develop symptoms leading to you cardioverting is never a good feeling...so don't go there. Allow the patient to self convert while en route to the hospital (highly likely) or closely monitor and prepare to act if symptoms develop.



Once again another "roll the dice" kind of answer. :wacko:


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## WTEngel (Nov 20, 2010)

Well then we agree to disagree.

If you think pushing adenosine is not a roll of the dice then you are mistaken. 

You still haven't answered whether or not you would sync cardiovert this patient... And what would your reasoning be for not doing so?


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## Akulahawk (Nov 20, 2010)

SoCal said:


> Once again another "roll the dice" kind of answer. :wacko:


Actually, not so much. Basically, if they appear to be compensating, let them be. Start a line, place the defib pads, perhaps have them do a valsalva maneuver, but otherwise, let 'em be. They'll spontaneously convert themselves or they'll start to decompensate. If the latter happens, well, you're already set up. At that point, the risk/benefit ratio swings in favor actively attempting to terminate the offending rhythm.


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## SoCal (Nov 20, 2010)

WTEngel said:


> Well then we agree to disagree.
> 
> If you think pushing adenosine is not a roll of the dice then you are mistaken.
> 
> You still haven't answered whether or not you would sync cardiovert this patient... And what would your reasoning be for not doing so?



1. I agree with that statement.
2. It is not rolling the dice, it is treating the patient who obviously is feeling something that he can't describe, but is affecting him.
3. In my protocols it only describes the indication for cardioversion reserved for hemodynamic instability, so if I gave him the adenosine and he became hemodynamically unstable, then yes I would, hands down. 

If I gave him one dose and he didn't convert, then he gets the repeat dose.


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## WTEngel (Nov 20, 2010)

It is rolling the dice... You have three possible outcomes. No change, conversion, or destabilization. 

We have a patient in stable SVT, with no hemodynamic compromise. Adenosine will stop this patient's heart, in and of itself causing a hemodynamic compromise, possibly leading to a worsening of the patient condition, or possibly making it better... We have no idea of knowing. Roll of the dice, just the same as monitoring the patient for signs of instability will either see the patient improve, stay the same, or deteriorate. 

The only difference in my eyes is that nothing I did to the patient had the possibility of making him deteriorate.

In a way you have changed the argument a bit. Are you saying that because the kid does have a funny feeling in his chest that he is for all intents and purposes symptomatic, and he should get the adenosine?

And last, but not least... What if your second dose of adenosine does not work? Do you consider cardioversion then? If your earlier argument still stands, you might as well cardiovert, bring the kid to the ER fixed, and save the ER the time and hassle of having to do it themselves...


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## SoCal (Nov 20, 2010)

WTEngel said:


> It is rolling the dice... You have three possible outcomes. No change, conversion, or destabilization.
> 
> We have a patient in stable SVT, with no hemodynamic compromise. Adenosine will stop this patient's heart, in and of itself causing a hemodynamic compromise, possibly leading to a worsening of the patient condition, or possibly making it better... We have no idea of knowing. Roll of the dice, just the same as monitoring the patient for signs of instability will either see the patient improve, stay the same, or deteriorate.
> 
> The only difference in my eyes is that nothing I did to the patient had the possibility of making him deteriorate.




*In a way you have changed the argument a bit. Are you saying that because the kid does have a funny feeling in his chest that he is for all intents and purposes symptomatic, and he should get the adenosine?*

Im not changing, I'm just offering a perspective that this pt. is symptomatic by what the OP said.

*And last, but not least... What if your second dose of adenosine does not work? Do you consider cardioversion then? If your earlier argument still stands, you might as well cardiovert, bring the kid to the ER fixed, and save the ER the time and hassle of having to do it themselves...*

Didn't think id have to say it again but, my protocols do not call for cardioversion in a pt who is not *hemodynamically unstable*. All I said is give the med. that you have for the problem.

Everyone is so focused on the bad side of what if, but what if you give the adenosine, he converts, feels relief, he's happy, parents are happy and you take him to the hospital fixed.


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## 18G (Nov 20, 2010)

Here is my thing with waiting. With kids, how do we know for sure how long they have been feeling the palpitations or other symptoms of the fast rate? If the child is out playing with their friends and the SVT isn't bad enough to cause them to stop playing right away, we could have a kid that has been in SVT for 2hrs before we get there. 

Why should we "wait" for them to decompensate before we decide to do something as was suggested? We all know SVT is a common occurrence in kids, we know adenosine is a pretty safe treatment, we know its indicated, we know adenosine works really well in most cases and has a super-short half-life, and we have the option of consulting on-line control prior to giving it. 

I don't believe that just because adenosine is given we should feel obligated to go to cardioversion. Explaining to a kid your gonna give them some medicine is much different than slapping two big patches on their chest with wires and telling them your gonna shock em! Even with sedation or analgesia I would imagine it would be pretty scary for them. 

What is the percentage of kids that resolve on their own without intervention? I could not find any statistic on this only that most kids outgrow SVT as an occurrence. 

How long is long enough to wait for kids to come out of SVT? 10mins? 30mins? two hours?


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## reaper (Nov 20, 2010)

Do we know how long this child has been maintaining a rate of 210?  This will not maintain forever. Just like any other muscle, it will start to wear down. With a child, we may not see this coming.

For me, I would want to know the extent of time that he has maintained at this rate. That will be a big factor in treatment decision.


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## 18G (Nov 20, 2010)

WTEngel said:


> 1) Adenosine will stop this patient's heart, in and of itself causing a hemodynamic compromise"...
> 
> 2) "We have no idea of knowing"
> 
> 3) The only difference in my eyes is that nothing I did to the patient had the possibility of making him deteriorate.



1) Adenosine does not always cause cardiac stand still. 

2) Adenosine is a well studied medication and we do kinda know the outcome as a direct result of research and the fact that adenosine is a med given tons of times over with its effects and safe administration observed and recorded. 

3) Withholding an antiemetic won't make someone deteriorate either but it's not best to withhold it. Not giving a narc to a patient with a fracture won't make em deteriorate either but its best not to withhold it. 

Granted, giving a cardiac med is more involved than giving some Zofran, but I don't think that should take away from the principle which is to treat your patients within the realm of your protocols and use your training and education to provide relief and resolution of a patients problem. Yes, sometimes waiting is apart of that, but to go along with what a few are suggesting we may as well never treat anything as were rarely ever 100% sure given the field environment and scope of pre-hospital care.


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## socalmedic (Nov 20, 2010)

there are many good arguments that i have read over the last few days. i feel most of them have great arguments as well. I tend to only treat symptomatic (ie, CP SOB) this is not because i am afraid of the drug, or having to cardiovert. it was explained to me a few months back by an interventional cardiologist while bringing in a false positive stemi (I am in the great MICN state of CA, what LP12 says must be true, but i conveyed that i didnt believe it), that if the patient is relatively stable (IE mild CP, mild SOB, sats stable, BP > 90) they want to see the patient before and durring conversion with a continuious 12 lead so that they can diagnose what the SVT is from and prevent it from reoccurring.

that may just be a regional thing but i understand where he was getting at. if i bring in an SVT patient they are always ready to receive them. i dont treat mild svt with anything, not even valsava. moderate SVT i consider treatment if i am more than 15min ish out. if they are unstable or very symptomatic they are getting electrical cardioversion, now.

this is just my way of treating them, i have not met an ED MD who has a problem with this. 

my vote is for wait, my explanation is above.


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## usalsfyre (Nov 20, 2010)

SoCal said:


> Didn't think id have to say it again but, my protocols do not call for cardioversion in a pt who is not *hemodynamically unstable*. All I said is give the med. that you have for the problem.
> 
> Everyone is so focused on the bad side of what if, but what if you give the adenosine, he converts, feels relief, he's happy, parents are happy and you take him to the hospital fixed.



First, you need to be able think outside your protocols, just because the book says "push adenosine" doesn't mean it's particularly appropriate. 

Second, what's your downside of being conservative? A few minutes of the kid not feeling well? Versus the downside of treatment being death in the field where he has two to five providers to work the code instead of an entire resuscitation team.


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## usalsfyre (Nov 20, 2010)

18G said:


> Why should we "wait" for them to decompensate before we decide to do something as was suggested?


We don't have to wait for them to fall off the cliff, but learn what to look for besides vital signs. Is the kid pale, cool or diaphoretic vs pink, warm and dry? Does he seem anxious? These are much earlier signs than a HR or B/P drop, and indicative of hemodynamic instability. 





18G said:


> How long is long enough to wait for kids to come out of SVT? 10mins? 30mins? two hours?



It's a fairly safe bet outside of other comorbidities kids can remain stable for a long time in SVT. 80 year olds walk around in afib with RVR all the time. They will warn you they're getting unstable, but you've got to assess further than what the Lifepack tells you.

I've seen an emergency physician, a couple med students and a guy who has probably saw more sick kids in a week then most of us will see in a career recommend caution. Granted, it's easy to not be who you say you are over the internet, but these individuals also have constructive knowledge to add to a discussion far beyond what most paramedics have, so I'm inclined to believe them. The only reasons I've seen for treating have been "protocol" and "why not" both of which are pi$$ poor reasons for any medical care.


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## SoCal (Nov 20, 2010)

usalsfyre said:


> The only reasons I've seen for treating have been "protocol" and "why not" both of which are pi$$ poor reasons for any medical care.



Not my point at all, I said treat because we are ALS providers with the knowledge about how this medication works and how the body works and can put the two together that this kid is feeling symptoms and is uncomfortable because of it and needs treatment. End of story. Yes my protocols back up my decision and like 18G said above, med-control is only a radio click away.

To defend my argument, I feel like running a code with my 3 to 6 providers is much more efficient and on point than a hospital, just from my experiences. 

Most Dr.s I bring pts into, want to see our 12-lead, and most of the time we transmit it over bluetooth and they have it before we even arrive, so they can see what is going on and don't need to see this kid in SVT on their monitor. 

Like ive said in my earlier posts, I offer my point of view, I am not saying any of these answers are wrong, just not my way of doing it.


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## 18G (Nov 20, 2010)

How would you answer a prosecutor if they asked you these questions for failing to treat and something bad happened as a result?

Why didn't you follow your medical protocol and treat the child who met the criteria?

Does your protocol allow for provider discretion to not treat patients when they meet criteria and to deviate on your own from standard protocol?
-------------
I think these are two very important questions. The majority seem to want to make the decision to hold off on there own without medical control consultation which I think is a bad idea. If your gonna stray than consult. I don't think there is any real good answers to the above questions when you intentionally do not follow protocol and do not consult with a doctor. 

The majority are using the argument that we as Paramedic's do not have the education to make the decision to treat pediatric SVT, yet the same majority is claiming to have enough education on their own to make the determination not to treat based on their great understanding of SVT. How can you do one and not the other?

If we do treat, we are treating based on a standardized criteria and standing order that was written by physicians. If it was such a bad idea and a high risk treatment than why is is so standard?


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## 18G (Nov 20, 2010)

*Adenosine and pediatric supraventricular tachycardia in the emergency department: multicenter study and review*.
Losek JD, Endom E, Dietrich A, Stewart G, Zempsky W, Smith K.

Children's Hospitals and Clinics, St Paul, MN, USA.
Abstract
STUDY OBJECTIVE: To determine the frequency of successful cardioversion and the adverse effects of adenosine treatment in pediatric emergency department patients with supraventricular tachycardia (SVT).

METHODS: This was a multicenter descriptive study with both prospective (convenience sample) and retrospective (chart review) patient entry. The setting was 7 urban pediatric EDs with a yearly census range of 22,000 to 70,000 visits. Pediatric patients 18 years of age and younger who received intravenous adenosine for presumed SVT were eligible.

RESULTS: Six investigators from 7 pediatric EDs entered 82 patients with 98 presumed SVT episodes (52 prospective and 46 retrospective) into the study. Twenty-five episodes occurred in children younger than 1 year of age. Eight patients had congenital heart disease, 59 had a history of SVT, 43 were taking cardiac medications (digoxin in 27), 13 had a history of asthma, and 25 presented in compensated cardiogenic shock. A total of 193 intravenous doses of adenosine were administered; doses were classified as low (<.1 mg/kg [n=18]), medium (.1 to <.2 mg/kg [n=116]), or high (>/=.2 mg/kg [n=59]). The dose range was.03 to.5 mg/kg, and only 2 doses were higher than.3 mg/kg. A total of 95 patient-events were determined to be SVT, all but 5 of which were atrioventricular (AV) node-dependent; 3 events were ventricular tachycardia. The overall cardioversion success rate of adenosine was 72% (71/98), and that for AV node-dependent SVT was 79% (71/90). Cardioversion was successful for 4 patient-events at a low dose, 44 at a medium dose, and 23 at a high dose of adenosine. Adverse effects occurred in 22 patients, and no patient had bronchospasm or hemodynamically significant arrhythmia.

*CONCLUSION*: Intravenous administration of adenosine led to successful cardioversion in 72% of pediatric ED patient-events that were presumed to be SVT. A dose range of.1 to.3 mg/kg was found to be most effective. *Adenosine was not associated with significant adverse effects.*


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## Shishkabob (Nov 20, 2010)

> Does your protocol allow for provider discretion to not treat patients when they meet criteria and to deviate on your own from standard protocol?




Actually, your protocols might not, but mine do.


Quoted from protocol book:




> It is incumbent on the prehospital clinician to understand that these clinical practice guidelines and policies can only provide guidelines for patient care.  The very nature of critical and emergency care delivery outside the walls of a hospital demand some level of autonomy and flexibility.  Clinician experience and judgement should be utilized to assure the best patient care




Oher protocols I've seen state the same thing:  Protocols do not take the place of sound clinical judgement. 

Essentially, "if you can defend it, you can do it"


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## 18G (Nov 20, 2010)

Mine do say a similar thing but they also say when you choose not to follow a protocol you need to consult with medical control. 

Again, a majority is saying we don't have the education to make sound decisions but yet we can deviate from medical protocol? I'm not following. You can't have it both ways.


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## usalsfyre (Nov 20, 2010)

18G said:


> How would you answer a prosecutor if they asked you these questions for failing to treat and something bad happened as a result?



Simple, the child while in my care was hemodynamicly stable, had no findings consistent with imminent decompensation and in my clinical judement it was best to wait until more resources were available to treat their condition. 

I in return ask this, how would you answer to a plaintiff's attorney if you treated a stable, hemodynamicly stable patient with no complaints other than a "fluttering" and it went go bad? 

Legally if this case goes bad your screwed either way, so forget that argument. Not to mention I HATE when providers try to use the legal system to jack the argument in their favor instead of relying on sound clinical judgement and what's good for patient care.


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## usalsfyre (Nov 20, 2010)

SoCal said:


> Not my point at all, I said treat because we are ALS providers with the knowledge about how this medication works and how the body works and can put the two together that this kid is feeling symptoms and is uncomfortable because of it and needs treatment.



Describe to me in detail pediatric SVT including cardiac conduction, accessory pathways, how cardiac output is affected ect. Got that? Good now describe adenosine, how it' metabolized, it's method and duration of action (at the cellular level) how it's excreted, ect. On the fly, not using the internet.



SoCal said:


> To defend my argument, I feel like running a code with my 3 to 6 providers is much more efficient and on point than a hospital, just from my experiences.


If you truly believe this you either 1). bring the patients to REALLY crappy EDs (not ruling this out, I've seen some really, really bad ones) or 2). have no clue what your watching and think running down an ACLS algorithm is all that's need for an arrest. 



SoCal said:


> Most Dr.s I bring pts into, want to see our 12-lead, and most of the time we transmit it over bluetooth and they have it before we even arrive, so they can see what is going on and don't need to see this kid in SVT on their monitor.



Agreed, but it's not about the physician seeing the condition. It's about the resources available to treat it.


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## Veneficus (Nov 20, 2010)

18G said:


> How would you answer a prosecutor if they asked you these questions for failing to treat and something bad happened as a result?



_Doubt very much I would be answering to a procecutor, perhaps a plantif attorney. If the kid got worse from the presentation depending on how worse, would determine if I went with adenosine or cardioversion. Since the cardioversion is the elective treatment, as well as the most potent indicated for the life threatening presentation, it should work where adenosine would fail.

"In my medical opinion, at the time of presentation, adding a chemical to stop the pts heart was not indicated. When it was apparent intevention was required, I performed the indicated intervention."_



18G said:


> Why didn't you follow your medical protocol and treat the child who met the criteria?




_Because I don't have a protocol for it and the child did not present needing immediate intervention._



18G said:


> Does your protocol allow for provider discretion to not treat patients when they meet criteria and to deviate on your own from standard protocol?



_At current, I have only to convince the attending overseeing me (who is usually only a few feet away) of my findings and treatment plan, I have yet to be denied. However, when I worked in EMS I always had a protocol that permitted sound clinical judgement in deciding to administer treatment and which ones._
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18G said:


> I think these are two very important questions. The majority seem to want to make the decision to hold off on there own without medical control consultation which I think is a bad idea. If your gonna stray than consult. I don't think there is any real good answers to the above questions when you intentionally do not follow protocol and do not consult with a doctor.



_What are you hoping the doc will tell you over the phone? There are only 2 options, give the adenosine and hold off. As I said before that decision will be made by liberal or conservative opinion of the doc you reach. You could ask 10 docs and get 11 different answers. But I gave my opinion if I was the doc in charge already. (I get to dress up and play doctor 6 days a week)_



18G said:


> The majority are using the argument that we as Paramedic's do not have the education to make the decision to treat pediatric SVT, yet the same majority is claiming to have enough education on their own to make the determination not to treat based on their great understanding of SVT. How can you do one and not the other?




_I think because the people arguing it are not the average paramedics as seen in the US in my experience. Once you start adding other medical or healthcare education to the 750 hours of paramedic vocational education, you get people who are more likely to use more information when making their decisions. As you can see from the discussion, there is more to it than "that is what the protocol said."_

_Several explanations that incorperate "sound clinical judgement" were put forth. It is not that I cannot be persuaded, it is that it takes some reasoning other than a protocol that is written for a majority of situations or this medication is "usually safe."

Do you "make people fit" when they present in a way that the protocol was not written for?

Considering the effectiveness of many EMS protocols and interventions, I hold them all suspect. I have finally made it to the point in my education where my independant judgement is being guided by the more experienced. I am not blindly following orders. When I have a question I also get a better answer than "the protocol says" or an assumption of usually. _



18G said:


> If we do treat, we are treating based on a standardized criteria and standing order that was written by physicians. If it was such a bad idea and a high risk treatment than why is is so standard?



Do you think physicians have some absolute knowlege? Do you think the protocols fit every patient? Is there a protocol for every patient? 

_I think they have written guidlines that require some judgement._

_It is not that I think adenosine is extremely high risk, I have pointed out the risks as well as the course of the patient's likely future in the hospital. In the risk/benefit and aggresive/conservative intervention I determiine this patient to fall into wait and watch. That is a accepted standard of care in many presentations of many diseases. (obviously not all)_



18G said:


> Adenosine and pediatric supraventricular tachycardia in the emergency department: multicenter study and review.
> Losek JD, Endom E, Dietrich A, Stewart G, Zempsky W, Smith K.
> 
> Children's Hospitals and Clinics, St Paul, MN, USA.
> ...


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