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.
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?
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?
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.
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?
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.
