# 4 year old with heart rate of 260



## PeacefulIce (Feb 14, 2015)

I was doing a ride today for emt-b class and one call was a 4 year old with a rapid heart rate. On arrival his heart rate was 260 bpm, temp 100.6 and oxygenation of 95%. 

He has had a cold and was vomiting yesterday but not today, mom said he has been eating and drinking today and woke up from his nap with his heart "beating out of his chest." 

How would you approach this patient?


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## Flying (Feb 14, 2015)

What is our general impression of the child?
Is the child's current mental status different from baseline?
Breathing rate and depth?
Quality of the skin and pulse?

How many hours ago did the child last eat/drink? Quantity/color of urine if any?
History? Medications? BP?

From a BLS viewpoint, I'd start from here and advance this to an ALS provider in whichever way your EMS system enables you to.


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## PeacefulIce (Feb 14, 2015)

Respiration was 40.  Blood pressure 80/60. History of apnea spells until age 11 months but otherwise healthy. Right arm was casted almost to the shoulder from a fall off his bunk bed yesterday afternoon. He was alert and talking. Mom said he had been drinking fluids and had peed this morning.


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## LACoGurneyjockey (Feb 14, 2015)

When did the fever start Were his apnea spells ever linked to anything, did he ever see a doctor for that? Do we have any pmhx? It sounds cardiac at this point, 260 just seems too fast to just be from the infection alone. What did his skin look like? Mental status? Capnography if available...
I'm not going to give this kid adenosine, and I'm not going to cardiovert him, but I'd really like to get him to the ER sooner than later. That BP is not confidence inspiring, he's compensating for something


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## NomadicMedic (Feb 15, 2015)

LACoGurneyjockey said:


> When did the fever start Were his apnea spells ever linked to anything, did he ever see a doctor for that? Do we have any pmhx? It sounds cardiac at this point, 260 just seems too fast to just be from the infection alone. What did his skin look like? Mental status? Capnography if available...
> I'm not going to give this kid adenosine, and I'm not going to cardiovert him, but I'd really like to get him to the ER sooner than later. That BP is not confidence inspiring, he's compensating for something



Interesting. No adenosine or cardioversion. What WOULD You do? Just put him in the truck and drive fast? 

How about a fluid bolus to start?


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## PeacefulIce (Feb 15, 2015)

Mom said apnea was from unknown cause. He wore an apnea monitor. Skin was cool and pale.

I'm confused, I asked about the kiddo and the medic said he had an undiagnosed concussion from the fall off his bunk bed. Vomiting was from concussion. Mom had taken him to the  family doc and not the ER for the fall and no one checked his head, just casted the arm.

Is this an autonomic nervous system reaction to the concussion?

What would you have looked for to suggest head injury?

Is tachycardia a frequent complication of concussion?


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## Chewy20 (Feb 15, 2015)

PeacefulIce said:


> Mom said apnea was from unknown cause. He wore an apnea monitor. Skin was cool and pale.
> 
> I'm confused, I asked about the kiddo and the medic said he had an undiagnosed concussion from the fall off his bunk bed. Vomiting was from concussion. Mom had taken him to the  family doc and not the ER for the fall and no one checked his head, just casted the arm.
> 
> ...


 
Was this "medic" on the call with you? If so then why wasnt the kid put on a monitor? Vomiting can certainly be from a concussion, but the medic cant "make" that diagnosis. Blood pressure is on the absolute low side of acceptable limits. Something neuro related is my guess, but not a concussion, at least not by itself.


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## PeacefulIce (Feb 15, 2015)

I was riding along for class, yes medic was on the call. He said he asked how the kid did and that's what he was told. It's third hand information coming to me but the conclusion was kid was admitted for complications of head trauma,  he said a concussion. 

On the call, he said cardiac illness was likely so I was wondering what would have differentiated cardiac from head injury/neurological causes on a similar call. 

Kid was on a cardiac monitor for the ride to the hospital.


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## chaz90 (Feb 15, 2015)

Cardiac illness? That's kind of an odd way to say that. 260 is profoundly tachycardic, even for a four year old. If that rate is from the cardiac monitor, and I'm 99% sure it is, the first thing I'd check is if the monitor is only picking up the QRS complexes to count it as a beat (like it should) or if there are amplified T waves (as often occurs in tachycardia) and the algorithm is picking these up as additional QRS complexes and artificially counting the heart rate as higher than it should. For a skinny pediatric, I occasionally end up turning down the amplification on the monitor to 0.5x from the standard 1x. Just something to keep in mind. 

If 260 is an accurate heart rate, your concussion diagnosing medic should certainly be thinking about doing something. A fluid bolus would be a great place to start, but if the patient complains of any strange feeling in his chest or something that might be described by an adult as palpitations adenosine would be a strong consideration. 

For whoever mentioned they would "consider" bringing in ALS, I would hope that period of consideration ends quite quickly with the decision to absolutely request them. Unless you have this patient in your BLS ambulance already and the hospital is 4 blocks away or positively no ALS is available, this should 100% be an ALS call. 

@Peacefullce, remember that things in medicine are rarely as black and white as they teach you in EMT school. There are numerous possible causes for tachycardia, and it's likely not nearly as simple as choosing whether it's an autonomic nervous system response or not.


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## RefriedEMT (Feb 15, 2015)

Wondering why so many are saying that he has an abnormal BP that is within normal ranges for a 4yo. Gotta remember how low BP is for someone that young. Average for that age is 88/65 making 80/60 very normal, thus the reason my EMT class trained us NOT to check BP on someone less than 4yo, since they will compensate then crash so quickly BP doesn't really help much for someone that age unless its abnormally high or low from the begining but then you have a critical PT that you should have been able to identify as critical w/o checking BP.


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## Flying (Feb 15, 2015)

chaz90 said:


> For whoever mentioned they would "consider" bringing in ALS, I would hope that period of consideration ends quite quickly with the decision to absolutely request them. Unless you have this patient in your BLS ambulance already and the hospital is 4 blocks away or positively no ALS is available, this should 100% be an ALS call.


I agree this patient fits criteria for ALS care. There should be NO delaying definitive care if what I stated before wasn't explicit enough.



RefriedEMT said:


> Average for that age is 88/65 making 80/60 very normal, thus the reason my EMT class trained us NOT to check BP on someone less than 4yo, since they will compensate then crash so quickly BP doesn't really help much for someone that age unless its abnormally high or low from the begining but then you have a critical PT that you should have been able to identify as critical w/o checking BP.


Where are we getting our numbers for a "normal" blood pressure? Chewy's judgement, a paramedic textbook and the NCBI blood pressure chart that comes up on Google all suggest that 80/60 is the lower limit, not the norm. Why should we refuse taking a blood pressure because of some stories in class? If our patient is "critical" to the naked eye, wouldn't the people who can actually do something for him want to know if his BP is abnormally high or low?


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## RefriedEMT (Feb 15, 2015)

The average BP I got 88/65 was from my EMT book (Brady- Emergency Care, 12th edition) and from a vital signs card I got from an RN who ran some calls with me in Olympia. It would not surprise me to find out some books have different recommendations but this is what I was taught and where I got the info I have available. The reason I gave that is because if their BP is very low they will have very obvious signs such as altered mental status and personally I will not waste time on a BP for someone that young UNLESS I have the time enroute although I would more than likely only palpate for the systolic since more than likely it would too loud due to the sirens and bumps. Also I never was told of any stories about something like this, I was told by my paramedic instructor that because children this young can crash so quickly a BP does not give a good indication of their priority. Consider this, you take BP it seems normal then your PT crashes on scene a minute later and your wondering what happened "his BP was fine".....It's all up to you, your protocols and what you were trained in the end but I wont wait around if my general impression is telling me to move now.


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## chaz90 (Feb 15, 2015)

I'm not bothered by the BP, though I would absolutely argue it's important to check it on this patient. The concerning thing to me is that this patient was reported to have a HR of 260. Regardless of what his BP is, his underlying problem needs to be addressed sooner rather than later.


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## CANMAN (Feb 15, 2015)

chaz90 said:


> I'm not bothered by the BP, though I would absolutely argue it's important to check it on this patient. The concerning thing to me is that this patient was reported to have a HR of 260. Regardless of what his BP is, his underlying problem needs to be addressed sooner rather than later.



Agree for sure. Having worked for a pediatric flight team for a bit this patient would be treated as cardiac until proven otherwise and I agree with chaz90 in this patient needs treatment now, or the blood pressure which your trying to figure out if it's normotensive or not is gonna crap out on you. Kids tolerate tachycardia due to fever, sepsis, medications, etc very well. SVT on the other hand, which this is, not so much. 220's for a 4 year old who is extremely septic, or febrile, or is amp'ed up on continuous Albuterol maybe, but not a kid who has a one day history of some vomiting and is currently tolerating PO intake and voiding. His "fever" is barely sometime most peds ER's would treat. There is a saying 38.0, medicate. This kid is right on that border. I would only be slightly more interested if he already had antipyretics on board. 

I would certainly consider a fluid bolus in this kid, but first would evaluate lung sounds, heart sounds, cap refill time, and check liver borders which will give you a good assessment of volume status in this kid. Based off those findings certainly a 20ml/kg bolus wouldn't hurt but I would want to rule out cardiac failure first as myocarditis could be a cause here. After that start with the Adenosine. 

I would withhold electricity until the kid doesn't respond to a fluid challenge, drops his pressure further, or has a change in mental status, which is most likely what you are going to see manifest if he is unstable and symptomatic due to the rate... At the hospital this kid would get labs, 12 lead, chest XR & maybe a head CT if he didn't have one post fall, some broad spec ABX based off his labs, and a cardiology consult before they would electively cardiovert him at this point.


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## Tigger (Feb 16, 2015)

RefriedEMT said:


> The average BP I got 88/65 was from my EMT book (Brady- Emergency Care, 12th edition) and from a vital signs card I got from an RN who ran some calls with me in Olympia. It would not surprise me to find out some books have different recommendations but this is what I was taught and where I got the info I have available. The reason I gave that is because if their BP is very low they will have very obvious signs such as altered mental status and personally I will not waste time on a BP for someone that young UNLESS I have the time enroute although I would more than likely only palpate for the systolic since more than likely it would too loud due to the sirens and bumps. Also I never was told of any stories about something like this, I was told by my paramedic instructor that because children this young can crash so quickly a BP does not give a good indication of their priority. Consider this, you take BP it seems normal then your PT crashes on scene a minute later and your wondering what happened "his BP was fine".....It's all up to you, your protocols and what you were trained in the end but I wont wait around if my general impression is telling me to move now.


Yes, this patient's blood pressure is probably not going to warn you if they are decompensating. That doesn't mean it's not useful information, and it's not wasting time. How long does it take to get a pressure? And automatically going to a palped pressure for your first one is poor form. Learn to auscultate in a moving ambulance.

Paint the clearest picture you can of what's going. That means getting a complete set of vital signs.


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## RefriedEMT (Feb 16, 2015)

Ive done many auscultated BPs in the ambulance I was just saying if its too loud because there have been many roads in olympia you just cant get a BP auscultated on unless your stopped and you don't stop for long when going priority. Pretty much every PT i've tech'ed I auscultated a BP before even starting to move, the only one I can remember I didn't bother trying to auscultate was a combative restrained PT who thought they were talking to god which prevented me from even attempting to auscultate since she wouldn't stop trying to get the restrains off of her by wailing her arms around as much as possible. Hell my partner (FTO) didnt even expect me to be able to get a palpated BP on her because of how she was acting, he seemed surprised at the fact I did, also I think In certain circumstances a palpated BP on a 4yo is not going to be that much of a different picture than an auscultated one; and either way the second could always end up being auscultated as you arrive at the ED of which I am sure will not change the care being given unless the BP changes dramatically.


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## COmedic17 (Feb 16, 2015)

Any endocrine issues?
Children typically don't have cardiac issues without a history. 

It almost sounds like an addisonian crisis.
Low BP, SVT, vomiting,chills, and fever are all signs. 

Trauma and illness can trigger an addisonian crisis. 

I know it's a far stretch, but onset can be any age. 


Was the pts blood sugar low?


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## Handsome Robb (Feb 16, 2015)

I'm going to agree with @chaz90 and @CANMAN . If his rate is truly 260 and the monitor isn't counting the T-waves as well I'm going to treat him. Sepsis is possible but like CANMAN said not likely with the story. IV, 20ml/kg bolus and if that doesn't work I'm going to move on to adenosine. If I'm not mistaken skin signs were pale and diaphoretic which indicates poor perfusion and basing BP off 70 + (age in years x 2) he's nearing what is widely considered as the lower limit in SBP for someone his age. I may have missed it but how is his mentation while we're with him? I know he was tolerating PO earlier but is he awake enough to now? If not I'm going to be more aggressive in my treatment. If I'm way far out and fluids and adenosine aren't effective I'd consider consulting with OLMD for sedation and cardioversion. If I'm close to the hospital and he's not declining I'd defer it but would definitely be giving an early warning to the ER that I'm bringing in a profoundly tachycardic child who's unresponsive to fluids and adenosine. Like others have said he's going to get a 12-lead as well and titrate O2 if needed. I'm not super interested in his EtCO2 personally but it's not a bad thing to check. With that said side stream cannulas aren't really known for their accuracy.

I also agree that cardiac issues in children are usually congenital however it wouldn't be the first time a child had an undiagnosed cardiac defect.


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## COmedic17 (Feb 16, 2015)

If anything cardiac- I would say possible WPW. But the fever doesnt really fit in with that.


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## Handsome Robb (Feb 16, 2015)

WPW is a definite possibility and if that's the case adenosine is definitely not what they need however the fever isn't high enough to indicate sepsis let alone severe sepsis with a compensatory HR that high.


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## COmedic17 (Feb 16, 2015)

Handsome Robb said:


> WPW is a definite possibility and if that's the case adenosine is definitely not what they need however the fever isn't high enough to indicate sepsis let alone severe sepsis with a compensatory HR that high.


It does indicate an addisonian crisis, though. 


Low BP, fever, chills, tachy, vomiting, onset can happen at anytime. And it can be perpetuated by illness and trauma. 


If I were thinking cardiac, I would go with WPW. But with his age and no cardiac history, an endocrine problem is a big possibility as well. 


But there's no way in hell I'm giving that kid adenosine. Not with the risk of WPW.


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## Handsome Robb (Feb 16, 2015)

COmedic17 said:


> It does indicate an addisonian crisis, though.
> 
> 
> Low BP, fever, chills, tachy, vomiting, onset can happen at anytime. And it can be perpetuated by illness and trauma.
> ...



I was under the impression that addisonian crisis was generally associated with severe illness rather than your run-of-the-mill cold but I may be wrong. It generally presents with hypoglycemia in pediatrics if I'm not mistaken. Adrenal insufficiency isn't something that strikes out of nowhere, there are signs leading up to it, many being the ones you brought up but for the little one to go from perfectly healthy to crisis would be  odd but again I very well may be mistaken. 

WPW is high on the list and if you're in a short transport situation then observe away but in an extended transport environment you're playing with fire by not acting with a kid who is presenting borderline hemodynamically unstable and will be well behind the eight ball if this kid falls off that decompensation edge. If you've got procainamide that'd be a great option here but not many if any agencies around where I'm at carry it.

With the logic that you're not giving adenosine because of the risk of WPW then why ever give it since there's always the risk? It's something like .03% of the population have WPW. Why not do 12-lead and assess for delta waves and discordant T waves? Granted with the rate it'd be difficult to see delta waves.


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## Carlos Danger (Feb 16, 2015)

Abrupt onset of severe tachycardia is most likely an electrical problem. Without seeing the EKG, this sure sounds like SVT. 

First line treatment for suspected SVT is adenosine as long as they are hemodynamically intact (and don't have a history of AF), which this one is for now. I would definitely start an IV if the kid will let me. Probably give a small fluid bolus to see if it helps. I'm not sure if I'd give adenosine right away or just watch the kid closely and give it at the first sign of any deterioration - I'd have to physically see the kid. A little phenylephrine may be quite useful here, if you have it. If the kid wants to fight me over the IV and appears otherwise appropriate - not anxious or uncomfortable, breathing easily -  then I'll take that as a sign that he's tolerating this well and I may be fine just watching him for the ride to the ED. Obviously having a low threshold for changing that plan of care quickly. Again, I'd have to see the kid and talk to him.

I can't say I have a lot of experience with endocrine issues, but this doesn't really fit the picture of adrenal crisis. Without a history to support it I'd say it's extremely unlikely, and wouldn't change our management in the field at any rate. 



PeacefulIce said:


> On the call, he said cardiac illness was likely so I was wondering what would have differentiated cardiac from head injury/neurological causes on a similar call.



Neurologic injuries generally don't cause tachycardia. Severe ones often cause bradycardia.


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## CANMAN (Feb 16, 2015)

Why not Adenosine for a pediatric patient with SVT regardless if WPW is suspected, in kids 99.9 percent of the time the treatment is going to be the same. Adenosine only becomes an issue with WPW if they have Atrial Fib, when's the last time you treated a 4 year old with A-fib...?


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## CANMAN (Feb 16, 2015)

Poor post on my part lol, will reply with my justification after some sleep and not coming off a 24haha. Basically my point is 99% of your peds SVT cases aren't going to be WPW, and thus why I said 12 lead etc in the hospital work up followed by a cardiology consult. In patients with an underlying atrial issue such as a-fib or flutter surely we don't want to give Adenosine in the setting of SVT for the obvious ventricular issues already stated, however I don't think that's what we are dealing with here and as Remi said  this is most likely an electrical problem that just hasn't declared itself before age 4. Different peds Cardiology docs will approach SVT with a concern of WPW different ways, and while adenosine may not be a first line choice for some, it is/can be safely given due to the rarity of a complicating atrial underlying rhythm in a 4 year old.


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## COmedic17 (Feb 16, 2015)

Handsome Robb said:


> I was under the impression that addisonian crisis was generally associated with severe illness rather than your run-of-the-mill cold but I may be wrong. It generally presents with hypoglycemia in pediatrics if I'm not mistaken. Adrenal insufficiency isn't something that strikes out of nowhere, there are signs leading up to it, many being the ones you brought up but for the little one to go from perfectly healthy to crisis would be  odd but again I very well may be mistaken.
> 
> WPW is high on the list and if you're in a short transport situation then observe away but in an extended transport environment you're playing with fire by not acting with a kid who is presenting borderline hemodynamically unstable and will be well behind the eight ball if this kid falls off that decompensation edge. If you've got procainamide that'd be a great option here but not many if any agencies around where I'm at carry it.
> 
> With the logic that you're not giving adenosine because of the risk of WPW then why ever give it since there's always the risk? It's something like .03% of the population have WPW. Why not do 12-lead and assess for delta waves and discordant T waves? Granted with the rate it'd be difficult to see delta waves.


I have Addison's disease. 
It's adrenal insufficiency. It's cronic and an addisonian crisis is an acute "attack" of it. It CAN be perpetuated by illness or trauma, but can even be spontaneous. But yes. That's why I asked about BG. It tanks when cortisol levels drop. Not just in children, but adults too. The onset can last years. It took years to figure out why I was always tired. Then my feet turned orange. Yes orange. But anywho, 



Because it's a 4 year old with no cardiac history. If it's afib RVR, no. If its WPW, no. I would not give adenosine because a handful of possible diagnoses contraindicated adenosine. I would have to see the 12 lead. But since I havent, and from what I have heard, he's not getting adenosine.


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## COmedic17 (Feb 16, 2015)

if your thinking electrical , it could be sick sinus syndrome. For which adenosine is also contraindicated. They can have episodes of bradycardia OR tachycardia.


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## Carlos Danger (Feb 16, 2015)

COmedic17 said:


> It's cronic and an addisonian crisis is an acute "attack" of it. It CAN be perpetuated by illness or trauma, but can even be spontaneous.



I think we all understand that, I just don't see why you'd assume that in an otherwise healthy four year old, 1 day of illness + apparent SVT = addison's disease. I just don't see how those puzzle pieces fit together.


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## COmedic17 (Feb 16, 2015)

Remi said:


> I think we all understand that, I just don't see why you'd assume that in an otherwise healthy four year old, 1 day of illness + apparent SVT = addison's disease. I just don't see how those puzzle pieces fit together.


I also said other possibilities such as WPW or sick sinus syndrome.  it's extremely unlikely to be cardiac in a child that young without a cardiac history. The main reason children code is from respitory emergencies. Spontaneous related cardiac emergencies in children are an EXTREMELY rare occurance.


Low blood pressure- cortisol directly effects vascular tone and function. High pulse- compensation for low BP, along with vomiting and fever. 


The parent also stated the child had periods of unexplained apnea during infancy. A known possible cause for periods of unexplained apnea and sometimes seizures during infancy is hypopituitarism. Which later in life if not treated manifests and effects other endocrine glands, leading to things such as hypothyroidism, adrenal insufficiency, etc etc.
Also, damage to the pituitary gland can cause this. However, I doubt his fall was significant enough to cause this. 

Which is why I asked what the blood sugar was. If noticeably elevated I'm going to consider sepsis. If it's low, it's probably endocrine. although low BG alone can instigate SVT,it's unlikely the pt would have a fever, and the mother stated the child had been eating, so it wouldn't  be low Without a reason.


Is it likely, no. But neither is a cardiac event on a healthy 4 year old.


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## PeacefulIce (Feb 16, 2015)

Thanks ever so much for all the responses, you all went waaaaaaaaay above my head, but I've been reading, looking up and learning from your posts. Much appreciated.

His blood sugar was 77. If I've not answered before, his colour was pale.

The paramedic I was riding with wasn't the personable sort of chap, to the little one, his mom or anyone else, so asking him any questions would have been pointless.  He did get an IV and put the kiddo on fluids.


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## Carlos Danger (Feb 17, 2015)

COmedic17 said:


> I also said other possibilities such as WPW or sick sinus syndrome.  it's extremely unlikely to be cardiac in a child that young without a cardiac history. The main reason children code is from respitory emergencies. Spontaneous related cardiac emergencies in children are an EXTREMELY rare occurance.
> 
> 
> Low blood pressure- cortisol directly effects vascular tone and function. High pulse- compensation for low BP, along with vomiting and fever.
> ...



Well yeah, it _could be_ a lot of unlikely things. But it generally doesn't make a lot of sense to keep looking for zebras when the horses are right in front of you. _Especially_ when the recommended treatment (IVF, adenosine, cardioverson) is the same regardless.

In actuality, a cardiac etiology is a much more likely explanation than adrenal insufficiently. Notwithstanding the fact that adrenal insufficiency is not a widely recognized cause of SVT,  as many as 1 in 250 pediatrics experience SVT. Versus estimates of the incidence of Addison's disease being 1-16,000 - 1-100,000; probably much lower in the pediatric population, since it predominates in the 30-50 age range.


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## Sunburn (Feb 20, 2015)

PeacefulIce said:


> The paramedic I was riding with wasn't the personable sort of chap, to the little one, his mom or anyone else, so asking him any questions would have been pointless.  He did get an IV and put the kiddo on fluids.



Medic did fine.

Guys, it's great to speculate, but zebras much?
You have a skinny 4y.o. with recent head trauma, vomiting, had a cold recently, maybe diarrhea. Granted you have info on urine, but not on amount.
He probably whacked his head, vomited a lot more than he drank and is dehydrated. A lot. Even his BP is lowish.
Kids can't comp blood and fluid loss with vasoconstriction because they lack the volume, so they skyrocket their pulse. That is the same reason they crash from high BPs as opposed to adults.
Putting him on fluids is more than enough for first aid until you get to the hospital. Try carotid sinus massage as well. It won't bring his pulse to normal but it may stretch them enough to get a better EKG reading.
That should give you time to see the changes. If fluids don't work then it may be heart, but I'd wager he's dehydrated.


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## gotbeerz001 (Feb 20, 2015)

PeacefulIce said:


> The paramedic I was riding with wasn't the personable sort of chap, to the little one, his mom or anyone else, so asking him any questions would have been pointless.  He did get an IV and put the kiddo on fluids.



For what it's worth, when I have a stat pedi call and family is unable to give me the information I need, I don't necessarily come off as personable either. My questions are direct and I want the information. 

Example:
Me: When was the last time your son had a seizure like this?
Them: It has been a while. 
Me: Okay, weeks? Months? Or Years?
Them: Yeah. 

That being said, I always have a follow up conversation at the hospital after TOC and make sure that everyone understands where each other was coming from and thank them for their help in the tx of their kid.


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## Brandon O (Feb 22, 2015)

Do a 12-lead.

I like to ruminate as much as the next guy, but sometimes the right answer is which test to do next, not a diagnosis.


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## JeffT (May 6, 2015)

new kid on the block here. Just gotta say, thank you for participating in this interesting conversation.  Love this forum and all of you guys posting here. Looking forward to many years of reading and posting here in the future.


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## Knightinwhitesatin (May 6, 2015)

Next question how would you transport this in? Code 3 or code 2? Go to close basic hospital or a farther children's hospital?


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## MackTheKnife (May 6, 2015)

Chewy20 said:


> Was this "medic" on the call with you? If so then why wasnt the kid put on a monitor? Vomiting can certainly be from a concussion, but the medic cant "make" that diagnosis. Blood pressure is on the absolute low side of acceptable limits. Something neuro related is my guess, but not a concussion, at least not by itself.


80/60 for a 4yo on the absolute low side? No.


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## Chewy20 (May 6, 2015)

MackTheKnife said:


> 80/60 for a 4yo on the absolute low side? No.



um yeah.


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## Carlos Danger (May 6, 2015)

MackTheKnife said:


> 80/60 for a 4yo on the absolute low side? No.



I think you guys are both right.

SBP of 80 is definitely a little low for a 4 year old, as a _normal _SBP. 

For a _sick_ 4 year old though, 80 isn't that low.  

Median SBP is about 90 + (2 x age in years), and minimum acceptable SBP is 70 + (2 x age in years)

http://www.fpnotebook.com/CV/Exam/PdtrcVtlSgns.htm


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## MackTheKnife (May 6, 2015)

Chewy20 said:


> um yeah.


Um, how many small, adult females do you know with similar BPs?


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## LACoGurneyjockey (May 6, 2015)

MackTheKnife said:


> Um, how many small, adult females do you know with similar BPs?


Ok, so then please enlighten us. What is the absolute low side for this patient, and what is normal? According to you. And we'll just disregard the widely accepted means of determining normal SBP on a child, for whom you do not have an endless trend of BP's to compare to.
I can't say I regularly check BP's on most small, adult females I know. Now prophylactic 12 leads are a different story *questionable ethics emoticon*


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## Chewy20 (May 6, 2015)

MackTheKnife said:


> Um, how many small, adult females do you know with similar BPs?



I'm sorry, is that a serious question? If I am understanding you right, you think an 80/60 is an ok pressure in a small ADULT female? So if you are in the field and see that on the monitor you just say, "hey you are a small adult female, nothing to be concerned about, oh except you may be in shock."

Am I missing something here, someone? Bueller?


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## RefriedEMT (May 7, 2015)

80+(2x4)=88 being the AVERAGE, so.....ok...


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## johnrsemt (May 7, 2015)

80/60 is ok in an older large adult male (at least this one) so it can be ok in anyone.  Just depends what there press is normally


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## LACoGurneyjockey (May 7, 2015)

RefriedEMT said:


> 80+(2x4)=88 being the AVERAGE, so.....ok...


Yes. And 70 + (4x2) being the low limit, so 78. His BP is 80. How is that not on the low end? I realize everyone may have vital signs that are normal at whatever you want. But we have a means of determining normal when you don't have a baseline for a reason. 
So if you found an unconscious adult patient with a SBP of 80, you would call that normal and move on?


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## StudMartin (May 7, 2015)

Nothing happens in a vacuum. I think everyone is too focused on a number. The number doesn't "really" matter. It's all about the overall presentation. For arguments sake, I have a pt with a BP of 70/40 who's mentating, walking, talking, perfect picture of health, I'm not going to be too gung ho to do much for them at all as far as interventions. Even though the 70 SBP is textbook "low."


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## RefriedEMT (May 7, 2015)

LACoGurneyjockey said:


> Yes. And 70 + (4x2) being the low limit, so 78. His BP is 80. How is that not on the low end? I realize everyone may have vital signs that are normal at whatever you want. But we have a means of determining normal when you don't have a baseline for a reason.
> So if you found an unconscious adult patient with a SBP of 80, you would call that normal and move on?



The equation i stated was for pediatric pts only.


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## LACoGurneyjockey (May 7, 2015)

RefriedEMT said:


> The equation i stated was for pediatric pts only.


Sorry, I read the post below yours as being from you too, disregard



nikc12 said:


> Nothing happens in a vacuum. I think everyone is too focused on a number. The number doesn't "really" matter. It's all about the overall presentation. For arguments sake, I have a pt with a BP of 70/40 who's mentating, walking, talking, perfect picture of health, I'm not going to be too gung ho to do much for them at all as far as interventions. Even though the 70 SBP is textbook "low."


I'm not saying focus in on the pressure and nothing else. This was more a response to @MackTheKnife saying the kids pressure was fine


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## RocketMedic (May 8, 2015)

I'd call it SVT and treat as appropriate.


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