4 year old with heart rate of 260

[COmedic17]

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.

 

[Handsome Robb]

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.

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.

 

[Carlos Danger]

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.

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.

 

[CANMAN]

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...?

 

[CANMAN]

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.

 

[COmedic17]

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.

 

[COmedic17]

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

 

[Carlos Danger]

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.

 

[COmedic17]

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.

 

[PeacefulIce]

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.

 

[Carlos Danger]

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.

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.

 

[Sunburn]

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.

 

[gotbeerz001]

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.

 

[Brandon O]

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.

 

[JeffT]

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.

 

[Knightinwhitesatin]

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

 

[MackTheKnife]

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.

 

[Chewy20]

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

um yeah.

 

[Carlos Danger]

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

 

[MackTheKnife]

um yeah.

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