# 3YO Male, Sick



## Tigger (Jan 14, 2020)

You're called to a pediatrician's office for a 3yo male "sick person, possible flu."

You find your patient in an exam room, seated with no assistance on the table. He tracks you as you walk in and interacts appropriately. You note his skin to be quite pale and he is on a simple mask at 4lpm. Though he appears tired, he still has normal strength throughout all extremities. Mom reports that she brought him today for flu like symptoms that have been going on for four days. Symptoms include a fever of 101.7, chills, and a productive cough. Mom reports that sometimes his coughs "sound just like a seal" but that this has not happened in several hours. Mom also relates some diarrhea over the past several days. She denies any medical history for the patient and states that she has been giving tylenol as directed for fever.

Out in the hall, you have a conversation with the pediatrician who reports that rapid flu and strep are both negative. She tells you that the patient was lethargic on arrival and hypoxic on arrival at 85% with increased work of breathing. With oxygen, the patient is satting at 95% with a good pleth and has only a minimal increase in work of breathing, his mentation has also improved. The doctor would like the patient transported to the local children's hospital, which is about 25 minutes away and also your closest facility. They are not able to acquire any lab work for you, though the doc states she is "concerned about leukemia."

Your assessment reveals the following:
Mental Status: Alert/Oriented, interacting in an age appropriate manner.
Skin: Pale, warm, dry.
HEENT: Pupils equal/round/reactive. Atraumatic. Neck supple.
Chest: Equal rise and fall bilaterally. Minor accessory muscle use noted. Rhonchus lung sounds noted in BL lower fields. 
Abdomen: Soft, non-tender, non-distended.
Pelvis: Stable, non-incontinent.
Extremities: Good distal perfusion x4.
Neuro: No apparent deficits.

No signs of non-accidental trauma or anything like that. Mom is there and is very helpful with history questions. The patient appears well nourished and cared for.

Vital Signs:
HR: 245. You think you can feel a brachial and carotid but you can't count. Strip is below.
RR: 24, moderately labored.
BP: 90/40 (manual).
SpO2: 95% @ 4lpm
Temp: 101.7 temporal

Given that mom is there, you attempt IV access with her help in the office. Following two attempts for 24ga catheters in the hand and foot, you are not able to obtain an IV. There might be an EJ you can access with a 22 but the patient is quite difficult to keep still.

So now what? What's your treatment plan? How will you transport?


----------



## PotatoMedic (Jan 14, 2020)

I have a sick patient, probably dehydrated, with a stable tachycardia.  I'm going to plop him on my gurney and drive.  I don't want to cardiovert without a line and would want to do fluids first before adenosine.  

If he deteriorates I'll consider the ej but probably io the kid and treat as appropriate.


----------



## MEDicJohn (Jan 14, 2020)

Establish IV fluids for the dehydration. Keep both mom and child super calm no agitation. PREP a possible nebulized treatment  and ET just as a last prep for the worst. Obviously continue to monitor enroute. Stable tachy is concerning


----------



## Tigger (Jan 14, 2020)

MEDicJohn said:


> Establish IV fluids for the dehydration. Keep both mom and child super calm no agitation. PREP a possible nebulized treatment  and ET just as a last prep for the worst. Obviously continue to monitor enroute. Stable tachy is concerning


As stated, you are not able obtain PIV access on this patient. Maybe you could get an EJ. Big maybe.


----------



## MEDicJohn (Jan 14, 2020)

Tigger said:


> As stated, you are not able obtain PIV access on this patient. Maybe you could get an EJ. Big maybe.



IO access if no PIV


----------



## E tank (Jan 14, 2020)

This, 


MEDicJohn said:


> Keep both mom and child super calm no agitation...


and this


MEDicJohn said:


> IO access if no PIV


are contradictory statements.


----------



## Peak (Jan 14, 2020)

I think this becomes a question of how sick do you think the kid is. The presentation you describe isn't reassuring, but if he can make it 25 minutes without intervention that transport may he the best option. Likely he has been like this for hours or days. 

I think this also depends greatly on skill level. I have zero problems placing an EJ in a toddler, but I've done countless on infants (and older patients). That being said most prehospital providers don't see a lot of peds, especially sick kids, so most likely most people considering this case would not be successful in accessing his EJ.

This kid obviously needs a full workup, but his hemodynamics are of immediate concern. A resting HR of 245 isn't normal even in the setting of mild fever, dehydration, and possible anemia. Even in infants a heart rate that high prevent adequate refilling of the heart and is detrimental to perfusion. Was there any variability to his HR? I do think that he needs SVT to be ruled out.

What is his BGL? 

If he doesn't look stable he needs access, IO if necessary. If no concern for CHD or heart failure 20 CC/kg of an isotonic fluid bolus. Likely you would be at the hospital by this time but consider PALS algorhythm for SVT or other deterioration in cardiopulmonary status. Bonus to a bolus is you can plump up his veins for the hospital. 

Dont delay transport for USGPIV or other such things, if he does end up having leukemia with a fever antibiotic and antiviral timing is going to be huge for his outcome. Work in the back of the bus. 

If you have a very high suspicion for SVT you could try to pop him out with vagals.


----------



## PotatoMedic (Jan 14, 2020)

Peak said:


> I think this becomes a question of how sick do you think the kid is. The presentation you describe isn't reassuring, but if he can make it 25 minutes without intervention that transport may he the best option. Likely he has been like this for hours or days.
> 
> I think this also depends greatly on skill level. I have zero problems placing an EJ in a toddler, but I've done countless on infants (and older patients). That being said most prehospital providers don't see a lot of peds, especially sick kids, so most likely most people considering this case would not be successful in accessing his EJ.
> 
> ...


Have any tips and tricks to share for pediatric EJ's?  I keep joking I could stick it in my kinds neck but I also know how much he wiggles around and that is what would deter me.


----------



## E tank (Jan 14, 2020)

PotatoMedic said:


> Have any tips and tricks to share for pediatric EJ's?  I keep joking I could stick it in my kinds neck but I also know how much he wiggles around and that is what would deter me.


 I got one, Spud...just get the kid to the hospital and don't even try...febrile, dehydrated kid with a HR of almost 300...flat veins and a jacked up mom? Askin' for trouble...


----------



## Tigger (Jan 14, 2020)

E tank said:


> I got one, Spud...just get the kid to the hospital and don't even try...febrile, dehydrated kid with a HR of almost 300...flat veins and a jacked up mom? Askin' for trouble...


Mom was not jacked up at all. Quite helpful in fact when we tried foot and hand. He had a noticeable EJ while sitting up and while I wasn't about to stick it, it was a possibility. I've only done EJs in obtunded kids, I honestly do not think we could have kept him still enough.


----------



## Tigger (Jan 15, 2020)

I did not run this call but was present so I can't quite provide everything. I can tell you that his HR stayed between 240-245 for the duration. In the interest of keeping the patient calm following IV attempts, a BGL was not obtained which I guess could go either way. A 12 lead was not obtained either, nor was EtCO2 though realistically there was no way anyone could keep a cannula in his nose.

I am not sure what this rhythm is. I called it sinus tach initially as I think you can see P waves in some leads. But 245 seems awfully fast for a three year old. The children's hospital informed me that "it's fast so therefore it's SVT even if there are P waves." They planned to give a single dose of a beta blocker if the rate didn't come down...though the patients blood pressure was 70/40 when we left 30 minutes later.

I think a more interesting question is if this kid is obtunded, profoundly hypotensive, and hypoxic on O2, at what point if any are you concerned about the rhythm and its potential contributions to badness? If it is SVT as a PALS instructor, I am obligated to tell you to cardiovert (lulz), but I don't know if I believe that.


----------



## PotatoMedic (Jan 15, 2020)

E tank said:


> I got one, Spud...just get the kid to the hospital and don't even try...febrile, dehydrated kid with a HR of almost 300...flat veins and a jacked up mom? Askin' for trouble...


I was asking more outside of the scenario in general terms.


----------



## Peak (Jan 15, 2020)

PotatoMedic said:


> Have any tips and tricks to share for pediatric EJ's?  I keep joking I could stick it in my kinds neck but I also know how much he wiggles around and that is what would deter me.



Positioning and holding traction is huge. I have someone hold the head, someone hold the chest if needed, and someone apply pressure and pull traction on the proximal aspect of the EJ using the side of a tongue depressor. As kids get bigger or are more cooperative/sedated I can have one person hold the tongue depressor and I can hold proximal (meaning closer to the chest) traction with my middle finger and distal traction with my thumb.

Like all EJs but especially with kids catheter choice is key. I prefer a braun cath over a BD autogaurd as the back part doesn't become an issue with their jaw. I will sometimes bend the needle to help with that as well. On larger EJs I've found the nexiva caths to work well too.

A lot of it is just practice though.


----------



## Peak (Jan 15, 2020)

Tigger said:


> I did not run this call but was present so I can't quite provide everything. I can tell you that his HR stayed between 240-245 for the duration. In the interest of keeping the patient calm following IV attempts, a BGL was not obtained which I guess could go either way. A 12 lead was not obtained either, nor was EtCO2 though realistically there was no way anyone could keep a cannula in his nose.
> 
> I am not sure what this rhythm is. I called it sinus tach initially as I think you can see P waves in some leads. But 245 seems awfully fast for a three year old. The children's hospital informed me that "it's fast so therefore it's SVT even if there are P waves." They planned to give a single dose of a beta blocker if the rate didn't come down...though the patients blood pressure was 70/40 when we left 30 minutes later.
> 
> I think a more interesting question is if this kid is obtunded, profoundly hypotensive, and hypoxic on O2, at what point if any are you concerned about the rhythm and its potential contributions to badness? If it is SVT as a PALS instructor, I am obligated to tell you to cardiovert (lulz), but I don't know if I believe that.



Depending on the rate and location of the re-entry node or ectopy center you can potentially see p waves in SVT, retrograde from the preceding complex. We especially see this in JET but can be seen in WPW and other SVT rhythms. Since kids can have pretty significant cardiac rotation without historic normal EKGs it is difficult to determine retrograde p waves in tachycardia.

I would establish venous access and give a dose of adenosine. I don't think it is unreasonable in these kids to place an IO if necessary to give fluids so that you can place an IV, and optimizing fluid balance will help to convert them out too (with preference given to plasmalyte or LR, but saline need not be excluded). Given some fluids and some oxygen if a patient breaks with adenosine and quickly goes back in then cardioversion is unlikely to bring any more benefit, but I wouldn't advise against the PALS pathway in the field.

If we dont break them then we will typically start a beta blocker, then amio, and then consider a sodium channel blocker. On occasion we can break them with a beta and then giving adenosine or cardioverting, but this should only be done in a cardiac PICU.

Kids with refractory SVT should be transferred to a ECMO center, which unfortunately that hospital is not.

Also a lot of people get hung up on giving agents that typically associated with hypotension to these patients. They have such poor atrial and ventricular filling that more often than not giving them that time to fill benefits their pressure more than the agent itself decreases pressure.


----------



## akflightmedic (Jan 15, 2020)

Can anyone educate me on why an EJ is even being discussed to this extent? I would just go IO and be done with it. Is there an obvious pro to the EJ over the IO relevant to this scenario that I am not picking up on prior to my coffee?


----------



## PotatoMedic (Jan 15, 2020)

akflightmedic said:


> Can anyone educate me on why an EJ is even being discussed to this extent? I would just go IO and be done with it. Is there an obvious pro to the EJ over the IO relevant to this scenario that I am not picking up on prior to my coffee?


I would say that there isn't anything special about doing an ej vs an io.  I just was curious if there was any special advice for doing them on a pediatric.  But as I said initially, I'd probably look for one if the kiddo deteriorated for about two seconds.


----------



## VFlutter (Jan 15, 2020)

akflightmedic said:


> Can anyone educate me on why an EJ is even being discussed to this extent? I would just go IO and be done with it. Is there an obvious pro to the EJ over the IO relevant to this scenario that I am not picking up on prior to my coffee?



Assuming pediatric would be a Tibial or Distal Femur IO so the flow rate and time to central circulation isn't all that great compared to an EJ PIV which means medications like Adenosine may be more likely to be effective with the latter? Just a guess


----------



## GMCmedic (Jan 15, 2020)

I think an IO is perfectly acceptable here. This kid needs fluid which may help the heart rate, but at the very least itll plump up the veins for better access if you need to go to adenosine (Im not convinced that you would). Im by no means a pediatric expert, but Im not to sure id transport without some sort of access.


----------



## Peak (Jan 15, 2020)

An IO is not an appropriate site for adenosine administration, an EJ can be. 

I think that many members of the medical community be it EMS, ED, or ICU staff forget than IOs are not a guarantee. Patients could have a history of OI or other wise have brittle bones that result in fracture even with the EZ IO product. Many kids end up with the needle going through the backside of the bone, and patients of all ages end up with oval shaped entrances either from the insertion or the needle inadvertently being moved back and forth during use. 

I have seen many kids who as a result or technique and/or confounding history have had two or three failed IO attempts by EMS and OSH EDs. 

I don't think that IOs are without merit, but they do have limitations just like any other form of access.


----------



## E tank (Jan 15, 2020)

I'm not seeing the urgent need for an IV right then and there. And I would not make any attempt at getting that HR down other than giving fluid (if fortunate enough to have an IV) Are folks really thinking about intervening on that?


----------



## Tigger (Jan 15, 2020)

akflightmedic said:


> Can anyone educate me on why an EJ is even being discussed to this extent? I would just go IO and be done with it. Is there an obvious pro to the EJ over the IO relevant to this scenario that I am not picking up on prior to my coffee?


I'm just throwing out what was apparent to me on my assessment to give folks a better idea of what I saw. 

If this patient was more obtunded, I might have tried. I dunno. Maybe I would have gone straight to IO. Pros and cons to both.


----------



## Tigger (Jan 15, 2020)

Anyway, I await the follow up from the receiving facility. Mostly I wonder what if anything was done regarding the rate and rhtyhm, which the hospital was convinced was "SVT" (not sinus tach, I asked). 

In the end, we tried twice to get a line and we not successful. Though the kiddo's skin looked awful, his mentation seemed quite appropriate. His lungs sounded pretty rhonchus but nothing close to stridor even when agitated. We left that alone considering his SpO2 on a relatively low supplemental O2. Some people say saline nebs help with this, I am not aware of evidence that really supports that but I suppose it would have been reasonable. Easy non-emergent transport to the children's facility in a car seat. 

Pretty straightforward, just thought that the HR and EKG added a little spice to what is usually a common and "easy" call. 

The real question I think is if you find this kid down at home and unconscious with the same backstory, what are you going to do? Obviously you will be obtaining access at some point be it IO or whatever. But do you presume that his illness is causing the rate/rhythm problem and call it compensatory or is the rate/rhythm problem causing critical illness _in addition_ to the URI stuff and therefore needs to be fixed in the field.


----------



## Peak (Jan 15, 2020)

One of the problems with dysrhythmia is you have you idea what the patients CO is without invasive monitoring or an echo.

Young kids compensate very well in their physical appearance but may have trivial cardiac output. Without personally seeing the kid we don't know how well he is actually doing, but with a heart rate of 245 on top of whatever is going on it isn't going to be too good.

SVT is a medical emergency. Prolonged SVT can lead to heart failure. There are many cases in the literature of patients who were not able to be converted out who had BNPs of over 10,000 in just a few days ultimately leading to heart failure and death. Kids have gone into complete cardiac failure and required transplant or even died on ECMO from SVT.

Access is a critical consideration in any cardiac emergency. I would not think poorly of any medic who is thinking about their access options in patient with potentially lethal arrhythmia.


----------



## MEDicJohn (Jan 15, 2020)

Tigger said:


> The real question I think is if you find this kid down at home and unconscious with the same backstory, what are you going to do? Obviously you will be obtaining access at some point be it IO or whatever.




ej are alot easier on someone who isnt moving. 

I agree the hr and ekg spice things up on this call. SVT i don't really see it i would of called it sinus tach as well, but i've been sitting behind a desk for a hot minute.


----------



## E tank (Jan 15, 2020)

> Peak said:
> One of the problems with dysrhythmia is you have you idea what the patients CO is without invasive monitoring or an echo.


You sure do...blood pressure, peripheral pulses. loc and distal skin signs, all of which were reasussuring with this patient.



> Peak said:
> Young kids compensate very well in their physical appearance but may have trivial cardiac output. Without personally seeing the kid we don't know how well he is actually doing, but with a heart rate of 245 on top of whatever is going on it isn't going to be too good.


A HR like this in a dehydrated, febrile kid shouldn't be surprising at all.



> Peak said:
> is a medical emergency. Prolonged SVT can lead to heart failure. There are many cases in the literature of patients who were not able to be converted out who had BNPs of over 10,000 in just a few days ultimately leading to heart failure and death. Kids have gone into complete cardiac failure and required transplant or even died on ECMO from SVT.


Anyone even considering attempting converting this kid by any means should not be in the position of taking care of sick kids.



> Peak said:
> Access is a critical consideration in any cardiac emergency. I would not think poorly of any medic who is thinking about their access options in patient with potentially lethal arrhythmia.


This is not a cardiac emergency.


----------



## Peak (Jan 16, 2020)

E tank said:


> You sure do...blood pressure, peripheral pulses. loc and distal skin signs, all of which were reasussuring with this patient.
> 
> 
> A HR like this in a dehydrated, febrile kid shouldn't be surprising at all.
> ...



Blood pressure is not a measure of cardiac output, but rather the resistance against the flow of cardiac output. In fact if measure arterial pressure in a patient in asystole they often have a pressure of 20 mmhg, and yet certainly don't have any CO.

While a brisk capillary refill is reassuring it does not preclude vasodilatory SIRS/shock or other mimics of good perfusion. In fact this child's pale presentation can also be noted as a skin sign, and one that could reflect poor CO.

No child should have a heart rate of 245 regardless of fever and dehydration and is almost exclusively reflective of more advanced disease. 

I'll let my director know I should not care for our fresh post op  hearts, thanks. 

Would you MSE this kid? What would be their ESI? This patient does in fact present an emergent condition.


----------



## MEDicJohn (Jan 16, 2020)

Peak said:


> I'll let my director know I should not care for our fresh post op hearts, thanks.




im confused here....... was this patient post op??????


----------



## Peak (Jan 16, 2020)

MEDicJohn said:


> im confused here....... was this patient post op??????



Not to my knowledge. It was my sarcastic response given the insinuation that my knowledge of pediatric dysrhythmia was incorrect or insufficient despite a very large portion of my job being to care for pediatric cardiac disease. Somehow my experience with the management of something so basic as SVT is insufficient despite this week me taking a day 0  fontan, glenn, and CAVC repair.


----------



## VFlutter (Jan 16, 2020)

Peak said:


> Not to my knowledge. It was my sarcastic response given the insinuation that my knowledge of pediatric dysrhythmia was incorrect or insufficient despite a very large portion of my job being to care for pediatric cardiac disease. Somehow my experience with the management of something so basic as SVT is insufficient despite this week me taking a day 0  fontan, glenn, and CAVC repair.



Not sure it was necessarily questioning your knowledge however, outside of the pediatric CTICU, saying SVT in this scenario is unequivocally a cardiac emergency is a little bit of a hyperbolie. Not all SVT is some channelopathy or structural heart disease nor likely will lead to irrevocable cardiac dysfunction.


----------



## E tank (Jan 16, 2020)

Peak said:


> Blood pressure is not a measure of cardiac output, but rather the resistance against the flow of cardiac output. In fact if measure arterial pressure in a patient in asystole they often have a pressure of 20 mmhg, and yet certainly don't have any CO.



So, the only way you can know that your patient has an adequate cardiac output is by a PA catheter or an echo. Got it.



Peak said:


> While a brisk capillary refill is reassuring it does not preclude vasodilatory SIRS/shock or other mimics of good perfusion. In fact this child's pale presentation can also be noted as a skin sign, and one that could reflect poor CO.



So, based on "could reflect poor cardiac output" in a kid with a bp of 90/40, what, besides giving fluid, should the medics on this call do assuming they got an IV?



Peak said:


> No child should have a heart rate of 245 regardless of fever and dehydration and is almost exclusively reflective of more advanced disease.


What does "more advanced disease" mean? That this child's HR and septic presentation are unrelated? Are you suggesting that they should intervene on that HR? And how will that inform the care the medics give to this patient 25 minutes away from a peds specialty hospital?


Peak said:


> I'll let my director know I should not care for our fresh post op  hearts, thanks.


When did we start talking about fresh post op hearts? I stand by the comment I made. So, would you or would you not have attempted to cardiovert this kid in the pre-hospital setting as presented? If you would, you have no business taking care of kids in that setting and I'll bet your director would agree with me.



Peak said:


> Would you MSE this kid? What would be their ESI? This patient does in fact present an emergent condition.



I have no idea what those things mean and I don't feel like googling them. I'm going to guess they are totally unapplicable to the scenario at hand as well.

As far as the "emergent condition" goes, yes, that would seem to be the case as the doctor called the paramedics. The question is, is it going to be made more of an emergency or less?


----------



## Peak (Jan 16, 2020)

E tank said:


> So, the only way you can know that your patient has an adequate cardiac output is by a PA catheter or an echo. Got it.
> 
> 
> 
> ...



That isn't what I said. I said that it is difficult to assess. A healthy appearing child who has normal vitals, a normal cardiac exam, and a normal general appearance will probably have good CO. We also have plenty of kids who are running around in heart failure undiagnosed who are well appearing and poor CO. There are many invasive monitors beyond a swan, which aren't really efficacious anyway and many studies show can be reliable for as few as 12 hours even when correctly placed. You can use a flotrack, compare RA and LA pressures, compare CA to CVP in post Glenn patients, take them to cath lab, perform a cardiac CT, perform a nuclear med study, et cetera. 

I didn't see this kid, and I don't necessarily think his care was inappropriate. I'm not going to place the same expectations on a 911 fire/EMS medic as I would on my team, as I said in my first post the best option for many medics would have been to load and go. I do think with several IV attempts at some point there was a drop of blood and a BGL could have been performed, I doubt it would have changed the patients clinical course and in this situation I'm not going to fault the medic since it is probably the first time he has seen a kid this sick. 

I worked in a fire service similar in structure to Tigger's current service, so when I say what needs to be done in EMS I try to think of back when I was a fire medic. Recognize that the patient has extreme tachycardia and a very sick general appearance. Rapidly transport to an appropriate facility (preferably to a pediatric ED). Give the abnormal HR print a strip. Provide supplemental oxygen. Consider access options, place an IV if reasonably possible, be ready to place an IO if the patient deteriorates further. If IV access can be obtained provide a 20cc/kg isotonic fluid bolus, to maintain PH and electrolyte balance LR is preferred (I would actually like plasmalyte but I've never seen it in the field). I cannot see this as not being SVT or some type of bizarre atrial/junctional ectopy, but slowing with fluids with suggest against those. Attempt vagals, it would be great if they got ice bags from the office but I wouldn't count it against them for not doing that. It would be great if they asked the office to give 10 mg/kg of motrin or toradol if they have it (0.5 mg/kg IV), but again I wouldn't hold it against the medic for not doing this. If you have a good IV, have given fluids without HR variability, and the patient continues to provide a good general appearance, and still and extended transport time consider a 0.2 mg/kg of adenosine; I do think rapid (although not lights and sirens) transport should be the priority and if you are working in the back of the bus they probably would have arrived to the ED by the point of considering adenosine. If the patient drops BP or becomes more altered consider electrical cardioversion. 

Personally I probably would have placed an EJ, bolused with LR, and given the adenosine if still indicated. By that time we would have arrived at the hospital. If I was in the field and expected a very long transport (several hours) I would call in for an order for a beta blocker or amio. Ketorolac or APAP for sure. If we are looking at an ED to ED transport I would want lytes, H&H, and a gas, consider appropriate replacement. The more we can get a patient to normal physiology the more likely we are to successfully convert him. 

We don't actually know that this child is septic. Viral infection, especially with dehydration and electrolyte abnormalities, as well as fever is notorious for putting kids in SVT. This isn't to say that he couldn't be septic as well as being in SVT. I would bet a lot of money that if he had been converted out he probably wouldn't meet sepsis criteria anymore. 

I'm also a mild bit cautious about the leukemia bit. What wasn't presented in the case study and I don't think Tigger knows is that about 5 years ago there was a failure to diagnose in a previously healthy toddler despite many visits of the preceding weeks and months with the POC repeatedly expressing their concerns to their PCP. When they presented to the ED NOC the patient was in late stage leukemia and septic meningitis and subsequently died shortly after. As a result the PCP community there is hyper aware of anything even vaguely resembling leukemia and I think that this is probably a red herring. 

Disease more advanced than simply being dry and febrile. For example cardiac or endocrine disease. 

I can tell you factually that if I rulled in unstable SVT and did not treat it that not only would my director be angry, but I'd probably be reported to the state for failure to treat. As far as the post OP heart bit, reentry rhythms are notorious in congenital heart disease surgeries, especially in CAVC and HLHS. I cannot believe that a medic doesn't seem to believe that SVT needs to be converted.

MSE is a medical screening exam mandated by EMTALA. ESI is the estimated severity index, the triage acuity system used in American EDs.


----------



## MEDicJohn (Jan 17, 2020)




----------



## Peak (Jan 20, 2020)

@Tigger Any updates from the hospital?


----------



## Tigger (Jan 20, 2020)

Peak said:


> @Tigger Any updates from the hospital?


I have a request in, still waiting.


----------



## johnrsemt (Jan 21, 2020)

Blood Glucose and 12 lead;

HR would be expected to go up maybe 15-20 for each deg of temperature, so it shouldn't be anywhere near that fast; and the BP is going to stay that good for long with that HR

SVT is not a rhythm a 3 year is going to tolerate long, especially that fast; so slowing it down with a couple of boluses is the preferred method but if it doesn't work.
IO would be great for fluid bolus/es  but you need PIV or EJ to give Adenocard.  So after a bolus or 2 if you still can't get an IV; you will end up having to cardiovert him.


----------



## VFlutter (Jan 21, 2020)

johnrsemt said:


> Adenocard....you will end up having to cardiovert him.



I really do not think it is wise to go down that road with this kid. Unless you are hours from a hospital and he starts deteriorating this is best left for a Pediatric Intensivist or Cardiologist to decided.  There are clearly multiple issues going on and SVT probably isn't the primary.


----------



## Peak (Jan 21, 2020)

VFlutter said:


> I really do not think it is wise to go down that road with this kid. Unless you are hours from a hospital and he starts deteriorating this is best left for a Pediatric Intensivist or Cardiologist to decided.  There are clearly multiple issues going on and SVT probably isn't the primary.



What is the most immediate threat to life?


----------



## VFlutter (Jan 21, 2020)

Peak said:


> What is the most immediate threat to life?



Immediate? Nothing 

You are advocating to cardiovert this kid with a 25 min ETA to a Pediatric Hospital? 

This is not something that needs to be treated in the back of an Ambulance without further diagnostics


----------



## Peak (Jan 21, 2020)

VFlutter said:


> Immediate? Nothing
> 
> You are advocating to cardiovert this kid with a 25 min ETA to a Pediatric Hospital?
> 
> This is not something that needs to be treated in the back of an Ambulance without further diagnostics



If you rule in SVT and the patient shows impaired perfusion, then yes I advocate for following the PALS recommendations.


----------



## Carlos Danger (Jan 22, 2020)

This is an easy one: Put the kid in the ambulance, keep him on O2, and drive to the pediatric hospital. Done.

If I had an IV, I'd give him some fluids. But I don't, so I can't.

If he decompensates enroute, then place an IO (or EJ, if you are feeling froggy) and manage per protocols. Yes, adenosine does work via IO. The literature supports it and I have personally done it.

Cardioversion and adenosine in a kid whose history you know very little about is not something to be taken lightly. 

If needed, 4mg/kg of sux IM will get you good intubating conditions without an IV.


----------



## Peak (Jan 22, 2020)

No BS we got an infant last night who coded mid flight who was being transferred to us from an OSH ED when the kid completely decompensated from their 'stable' SVT. We had to work the kid for about 20 minutes before we got pulses back. 

SVT can be a lethal rhythm that should not be taken lightly.


----------



## Carlos Danger (Jan 22, 2020)

Peak said:


> No BS we got an infant last night who coded mid flight who was being transferred to us from an OSH ED when the kid completely decompensated from their 'stable' SVT. We had to work the kid for about 20 minutes before we got pulses back.
> 
> SVT can be a lethal rhythm that should not be taken lightly.


Cool anecdote.


----------



## johnrsemt (Jan 28, 2020)

Cardioversion and adenosine in a kid whose history you know very little about is not something to be taken lightly;

Your right;  but with this thought we shouldn't treat a lot of the patients that we treat.

I have given Adenocard, and then cardioverted patients that I knew nothing about their medical history because they were unconscious.  Their friend had given them 2 doses of Narcan (because he thought it was an OD)  at least he tried.   Fire is yelling at me to IV push more Narcan (patient was breathing ok, just not awake).
I got a line, and my partner put him on a monitor and HR was over 200.  Pushed Adenocard and HR slowed down to about 80,  good 12 lead,  then sped back up to 210, 12 lead showed SVT.   I tried 12mg and got same results.  Cardioverted him twice before it broke enough that I could get a BP that was readable.  Ground transported him 130 miles to a hospital that could handle him, because we couldn't get a helicopter.    

I knew nothing about him, except his friend thought he OD'd  Turned out he had no drug history or drugs in his blood.   He also had no cardiac history, before that day.


----------

