Asthamtic with concurrent SVT

thegreypilgrim

thegreypilgrim

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You respond to an urgent care clinic for a 12 year old male brought in by family for asthma exacerbation.

HPI: Well-nourished, school-age child acting appropriately, A&O, and no signs of secondary sex characteristics (e.g. armpit hair, etc.). Began complaining of shortness of breath yesterday, took 3 puffs from prescription MDI (albuterol) which didn't help. Parents brought him to county-operated urgent care clinic where he has received 5 mg albuterol by nebulizer x 3.

Vitals: BP 114/60, HR 160, RR 28, SpO2 98%, skin signs WNL, pupils PERRLA, temp 99.9 F

History: asthma
Allergies: NKDA
Medications: albuterol

This child is still in moderate respiratory distress with both inspiratory and expiratory wheezing (although more prominent on expiration and in left lung base), and accessory muscle use. No complaints of CP, N/V/D, Weakness/Dizzyness, no JVD, no PE. The pt is displaying rather pronounced tremulous activity and appears anxious.

ECG shows a narrow-complex tachycardia in which p waves are difficult to distinguish.

You are an ALS unit with whatever complement of medications and equipment you normally carry in your jurisdiction with the exception that the only "respiratory" medications you carry are albuterol by nebulizer and NTG (which obviously isn't indicated here). There is a level II EDAP (Emergency Dept. Approved for Pediatrics) with a 10 min. ETA or a Level I PMC/PTC 15 min. away.

Have at it.
 
Paper bag, non-emergent transport to the nearest hospital. :rolleyes: jk



Well. While it can be labeled "SVT" technically, it's not symptomatic at the moment. Skin/BP/mental status are fine. So I'll let that go for right now.

What are his normal "triggers" for asthma? Hayfever, perhaps? This seems to me the asthma is secondary to something. Possibly an infection, given the temp.. Asthma attacks alone don't usually have a temp.

For now I'll call it "supportive care", and attempt to calm him. Head slowly and calmly to the L-1 ER. We can always divert to the closer one if things get worse.

I'd actually halt the albuterol neb to see if his HR/anxiety diminishes (possibly side effects of a crapload of Beta) but keep it nearby and ready to be administered again. And if we have it, get a flush and some Epi 1:1000 set aside incase he gets really tight and I want to call a Doc for some nebulized Epi.
 
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How long has he been at the urgent care?

I am not worried about the SVT, its not an immeadiate life threat and SVT in children is most likely caused by hypoxia or agitation.

While I wouldn't call this kid "severe" he is definately crook and has the potential to drop dead on us (which is bad).

I'd give him some more salbutamol and gain IV access (even if it is just a 20ga.) it's better to be prepared than piss arse around if he gets really bad.

The most important thing here is that we don't all space out and start gettin crazy, the calmer we are, the more relaxed patient will be and that just makes for nice smooth experience.

Monitor and transport.
 
He's been at the urgent care for about 1.5 hours.

Can't really determine "triggers" as there is a language-barrier with the family, and the kid doesn't really know.

I'd actually halt the albuterol neb to see if his HR/anxiety diminishes (possibly side effects of a crapload of Beta) but keep it nearby and ready to be administered again.
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See, this was what I was worried about but because he was wheezing so bad I was trying to weigh the risks of what was worse: poor ventilation or dysrhythmia (in other words "respiratory" vs. "cardiac"). Ultimately I left him on the nebulizer because the rhythm didn't seem to be causing any problems...indeed it was kind of hard to determine even if it was SVT since it's kind of hard to see p waves when kids get tachycardic anyway...I just presumed it was SVT. Especially since he was physiologically still very much a "kid" and hadn't really started developing into adolescence yet.

By the time we got the ED his lungs had cleared up according to the ED attending although he vomited all over our gurney...probably from all that albuterol. :huh:
 
No lung sounds?

I've seen quite a few people treated for asthma based on c/o dyspnea and verbal hx, but auscultation reveals clarity and pulse-ox is 100%. What I have found is the following in the cases I got and did not treat due to lalck of symptoms treatable with Albuteral:

1. Very rapid and sometimes irregular pulse.
2. Voluntary stridor.
3. Absolutely nothing remarkable.
4. Admits uses albuteral to "enhance" basketball performance.
5. Self-pre-treats before exercise.
6. Uses MDI as an expectorant for cough.
Over and over.
And I have seen the albuteral MDI sprayed on cigarettes and smoked by minors and inmates.

Coronary insufficiency can cause sensation of breahtlessness, you shoot in the MDI, pulse goes up, more breathless, more MDI, chest pain and SOB, more MDI, then the Kansas Sign (BEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEP....).
 
ECG shows a narrow-complex tachycardia in which p waves are difficult to distinguish.
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Are you sure it's SVT? It just sounds like tachycardia to me and it's very hard to differentiate the two, especially in peds (because of the higher "normal" values), without a 12-lead and even then I am hesitant to make the call myself unless I have no underlying explanation for the symptoms I am seeing.

I'd actually halt the albuterol neb to see if his HR/anxiety diminishes (possibly side effects of a crapload of Beta) but keep it nearby and ready to be administered again.
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Actually it's the undiferrentiated alpha effects of one of the enantiomers of racemic albuterol (the one that's not the medication known as levalbuterol (Xopenex) which is simply albuterol minus most of the side effects). I would be hesitant to load the kid up with multiple doses of albuterol, especially if he's not responding to the initial doses. Repeated doses of albuterol can actually worsen bronchospasm (paradoxical bronchospasm) through a mechanism that is not fully understood. Albuterol is probably the most widely abused drug in hospitals because it's viewed by many as a "harmless" drug due to its broad safety margin.

If he's not responding to the albuterol, you should look at other possible causes of the wheezing (if it's localized, it may be due to an aspirated foreign body for example) and/or move further down the treatment protocol for asthmatic exacerbation (steroids, etc). Get moving to the hospital and let them figure out what exactly is going on.
 
thegreypilgrim said:
because he was wheezing so bad I was trying to weigh the risks of what was worse: poor ventilation or dysrhythmia (in other words "respiratory" vs. "cardiac"). Ultimately I left him on the nebulizer because the rhythm didn't seem to be causing any problems...indeed it was kind of hard to determine even if it was SVT since it's kind of hard to see p waves when kids get tachycardic anyway...I just presumed it was SVT. Especially since he was physiologically still very much a "kid" and hadn't really started developing into adolescence yet.

By the time we got the ED his lungs had cleared up according to the ED attending although he vomited all over our gurney...probably from all that albuterol. :huh:
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Peds rarely have ACTUAL textbook SVT. Also, for someone of that age, you'd probably need to be well over 200bpm before you're hitting SVT-territory. Also remember, most pediatrics are infection or respiratory problems. Actual cardiac problems are rare, and usually have a known history.

And like yousaid, he was probably puking from the anxiety, which was probably caused by the attack and resulting multiple albuterol treatments. haha
 
Like others have said, the SVT isn't symptomatic so it doesn't necessarily warrant treatment at this point. Besides, there are several different ways the tachycardia could be caused by the asthma... compensatory mechanism for hypoxia, sympathetic tone from the fight or flight response, etc. 02, IV, monitor, bronchodilators, corticosteroids.
 
Anxiety from not breathing will run up your pulse rate.

Nice to know what if anything he was given by his family before brought in. Three or four albuteral MDI's? OTC epinephrine MDI's? Ephedrine, psudoephedrine, someone else's Rx?
 
why not give the kid a fluid bolus? most asthmatics can have an asthma attack triggered or partially triggered by mild to moderate dehydration... not to mention it may slow the heart rate down some especially if he is dehydrated. I would prefer to give the kid some steroids (we carry solu-medrol), a fluid bolus and possibly a dose of atrovent. There is the possibility the kid might have an pneumonia that exacerbated the asthma also, especially with the wheezing seeming to be worse in just one lobe of the lungs. I would also question the family and the child on any recent history of choking episodes, or the possibility of an aspiration type pneumonia occurring... or of any similar type episodes...especially with the fever... he's got something going on as far as an infection, as far as the etiology that remains to be seen based on labs and a chest x-ray... but definitely a fluid bolus, and treat him for a combination of asthma exacerbation and infection of some sort ( more than likely pulmonary in origin)
 
FLEMTP said:
why not give the kid a fluid bolus? most asthmatics can have an asthma attack triggered or partially triggered by mild to moderate dehydration... not to mention it may slow the heart rate down some especially if he is dehydrated. I would prefer to give the kid some steroids (we carry solu-medrol), a fluid bolus and possibly a dose of atrovent. There is the possibility the kid might have an pneumonia that exacerbated the asthma also, especially with the wheezing seeming to be worse in just one lobe of the lungs. I would also question the family and the child on any recent history of choking episodes, or the possibility of an aspiration type pneumonia occurring... or of any similar type episodes...especially with the fever... he's got something going on as far as an infection, as far as the etiology that remains to be seen based on labs and a chest x-ray... but definitely a fluid bolus, and treat him for a combination of asthma exacerbation and infection of some sort ( more than likely pulmonary in origin)
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This is also what I'm interested in. Fever + more wheezing on one side than the other = infection? Maybe infection + a reactive airway component.
 
Hmm, has he been "sick" lately? Any sputum/coughing up?

Could always try 500ml of NS KVO and see how that works.

A chest x ray would go down dandy here.
 
id prob d/c the neb and monitor..

is it possible the albuterol this child has received could be causing some hypokalemia?
 
is it possible the albuterol this child has received could be causing some hypokalemia?
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It normally takes extreme doses to produce a clinically significant hypokalemia. The potassium sequestration effect of albuterol is not that dramatic and is short lived in most people. There are a few case reports of hypokalemia with single or double doses of albuterol, but it may be that some people are more sensitive to the effect than others (my hypothesis....nothing more). I have only seen hypokalemia develop in two cases- one was a child who drank a bottle of concentrated albuterol (about 30x the adult dosage, so roughly 70mg) and the other was in a kid (12 or 13) who was abusing albuterol inhalers for the "high".

The more likely culprit is simply that the "SVT" was just extreme tachycardia. The less likely (but still more plausible) explanation is SVT induced by the adrenergic effects of the albuterol (which is documented in the literature far more often than hypokalemic issues), rather than something involving potassium derangements. Hoofbeats, my friend, hoofbeats.
 
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possibly a dose of atrovent. There is the possibility the kid might have an pneumonia that exacerbated the asthma also,
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My understanding is that Atrovent is not ideal for Tx of pneumonia, as it consolidates that mucous and makes it thicker, but have found little evidence to back this opinion up. Can anyone comment on this?
 
OK, at least tell us the outcome/Dx

Why the high cardiac rate with normal BP? Or is that a pediatric normal of some sort?
 
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