4 year old with heart rate of 260

[PeacefulIce]

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?

 

[Flying]

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.

 

[PeacefulIce]

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.

 

[LACoGurneyjockey]

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

 

[NomadicMedic]

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?

 

[PeacefulIce]

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?

 

[Chewy20]

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?

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.

 

[PeacefulIce]

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.

 

[chaz90]

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.

 

[RefriedEMT]

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.

 

[Flying]

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.

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?

 

[RefriedEMT]

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.

 

[chaz90]

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.

 

[CANMAN]

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.

 

[Tigger]

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.

 

[RefriedEMT]

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.

 

[COmedic17]

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?

 

[Handsome Robb]

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.

 

[COmedic17]

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

 

[Handsome Robb]

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.