3YO Male, Sick

[Tigger]

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]

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]

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]

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]

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]

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.


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


This is not a cardiac emergency.

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]

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]

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]

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]

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.

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?

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?

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.

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]

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.

 

[MEDicJohn]

 

[Peak]

@Tigger Any updates from the hospital?

 

[Tigger]

@Tigger Any updates from the hospital?

I have a request in, still waiting.

 

[johnrsemt]

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]

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]

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]

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]

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]

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.