Asymptomatic Pediatric SVT: Medicate or Wait?

[8jimi8]

I get the difference between symptomatic, cerebral hypoperfusiona nd irreversible cerebral hypoperfusion. In our over 1 hour transport times, these things matter. We never have the luxury of making the decision "now, or 10 minutes from now by the ER."

I respect your opinion on this, I'm just not clear. What's different about adenosine administration by a pediatric physician than a paramedic?

I think his implication is that the pediatric cardiologist, has enough education to take over when the pals algorithm moves to the "consult an expert" category.

 

[Aidey]

I respect your opinion on this, I'm just not clear. What's different about adenosine administration by a pediatric physician than a paramedic?

The pediatric physician can recognize WPW and the like.

 

[gicts]

Were 12-leads done? Under his condition, I think the best course of action would to monitor and try to pick up a reason as to why there is SVT. Did he end up being a direct admit, or was he converted in the ER?

 

[LondonMedic]

What's different about adenosine administration by a pediatric physician than a paramedic?

Absolutely nothing, it's just pushing a drug down an IV after all...

If you think a physicians blindly practice protocol driven medicine, I'd suggest that you remember that there is a significant difference between medicine and paramedicine.

 

[abckidsmom]

Absolutely nothing, it's just pushing a drug down an IV after all...

If you think a physicians blindly practice protocol driven medicine, I'd suggest that you remember that there is a significant difference between medicine and paramedicine.

Come on.

I'm really good at sarcasm too, but it really was a real question. Can you talk a little about what the issues might be?

 

[Outbac1]

On my own with an asymptomatic pt, monitor and transport. However you were in a pediatricians office with lots of equipment and drugs. In the medical version of Rock, Paper, Scissors Dr. trumps Paramedic. What did the Dr. want done? I would have referred to the Dr. and followed their advice.

 

[46Young]

Sounds like a great plan to me.


Here is some food for thought,

How would you have felt if you did give the kid adenosine, he converted, and the parents would have felt your efforts were enough and refused further treatment or transport?

Kind of similar to treating w/ ntg before obtaining a 12-lead. No evidence of STEMI will change the treatment course.

 

[46Young]

Kids stay dry. Almost all kids drink only to thirst, especially with school days and asking permission to visit the water fountain, etc. Thus, when there's an insult to normal, a fluid bolus appropriate to the child's weight is a fine idea, IMO.

I understand what you're saying, but there was no stated indication for fluid therapy. The pt wasn't in sinus tach, there was no hx suggestive of hypovolemia, the pt wasn't hypotensive, nor was the pt in cardiogenic shock that would benefit from increased preload. That's what I was getting at. To follow your logic, we would be giving most sick children presumptive fluid boluses by default. I prefer not to medicate unless indicated.

 

[18G]

abckidsmom... your thinking is right on.... arrogance is just rearing its ugly head again. A child in SVT with a rate over 220 that is showing signs of hemodynamic compromise needs treated right then and there. Adenosine is a drug with a great safety profile. Why let a poor child suffer and feel crappy for ten minutes and possibly deteriorate.

If anyone is unsure about giving adenosine than CONSULT ON THE RADIO OR BY PHONE WITH THE PEDIATRIC CENTER OR OTHER RECEIVING HOSPITAL AND GET ORDERS FROM A PHYSICIAN. I would have asked the pediatrician what his thoughts and opinions were regarding adenosine as well.

 

[18G]

.... on a side note....

so anytime we as EMS encounter a sick kid were not supposed to treat them because were not pediatricians, pediatric cardiologist, or the like?

 

[LondonMedic]

abckidsmom... your thinking is right on.... arrogance is just rearing its ugly head again. A child in SVT with a rate over 220 that is showing signs of hemodynamic compromise needs treated right then and there. Adenosine is a drug with a great safety profile. Why let a poor child suffer and feel crappy for ten minutes and possibly deteriorate.

In what way is the asymptomatic child in this scenario showing signs of heamodynamic compromise? Why does it need to be treated 'right then and there'?

so anytime we as EMS encounter a sick kid were not supposed to treat them because were not pediatricians, pediatric cardiologist, or the like?

Anytime you encounter any patient who does not need immediate stabilisation, there are several good arguments for transporting them and not :censored::censored::censored::censored:ing around on scene.

Maybe it is arrogance; yours if you think that a paramedic can do medicine better than a hospital.

 

[46Young]

Absolutely nothing, it's just pushing a drug down an IV after all...

If you think a physicians blindly practice protocol driven medicine, I'd suggest that you remember that there is a significant difference between medicine and paramedicine.

If an intervention is indicated (key word indicated), then it's negigent to not perform that intervention. Explain to me how it's legally defensible, and also acceptable prehospital pt care to withhold indicated medications.

 

[abckidsmom]

In what way is the asymptomatic child in this scenario showing signs of heamodynamic compromise? Why does it need to be treated 'right then and there'?

Maybe it is arrogance; yours if you think that a paramedic can do medicine better than a hospital.

I think the conversation had moved on to the hypothetical unstable kid who was 10 minutes from the ER. If you were able to calm down enough to address the questions instead of getting wrapped up in emotion, we could learn your unique point of view.

 

[8jimi8]

.... on a side note....

so anytime we as EMS encounter a sick kid were not supposed to treat them because were not pediatricians, pediatric cardiologist, or the like?

You are stacking inferences. No one said that. The original question was what would you have done with the Asymptomatic Pedi SVT. I think everyone agreed that waiting to treat was the right decision. Symptomatic is another story and no one said to withhold tx in that situation. Yes we are all eager to hear LondonMedics reply, tho there may not be one. But you don have to shout us down... We are all on the same page.

 

[LondonMedic]

If an intervention is indicated (key word indicated), then it's negigent to not perform that intervention. Explain to me how it's legally defensible, and also acceptable prehospital pt care to withhold indicated medications.

It's also negligent to delay transport because you think you know what's indicated.

:censored::censored::censored::censored:ing hell, if I had a quid for every sick patient that I've seen blued in with scene times of over an hour, I'd be buying more beer than I am now.

 

[46Young]

In what way is the asymptomatic child in this scenario showing signs of heamodynamic compromise? Why does it need to be treated 'right then and there'?


Anytime you encounter any patient who does not need immediate stabilisation, there are several good arguments for transporting them and not :censored::censored::censored::censored:ing around on scene.

Maybe it is arrogance; yours if you think that a paramedic can do medicine better than a hospital.

Not arrogance, but rather what we've been educated and trained to do. Doing our jobs. Furthermore, our protocols and guidelines dictate what and where we are to do these interventions. For example, NYC's protocols generally advise txp early on, and to do these interventions enroute to the ED. Not withhold treatments, but to not delay txp to do so.

http://www.nycremsco.org/images/articlesserver/ALS_Protocols_January_2010_v01012010d.pdf

 

[usalsfyre]

If an intervention is indicated (key word indicated), then it's negigent to not perform that intervention. Explain to me how it's legally defensible, and also acceptable prehospital pt care to withhold indicated medications.

I call BS. Part of being a competent clinician is having the discretion to not to perform specific interventions. It's done daily with regards to surgeries, meds for chronic conditions, ect.

 

[abckidsmom]

I call BS. Part of being a competent clinician is having the discretion to not to perform specific interventions. It's done daily with regards to surgeries, meds for chronic conditions, ect.

I can agree with this. "Indicated" can include a gray area where a competent provider may or may not decide to intervene. There is a medic I really respect who tends toward doing every. single. intervention he can for every patient he interacts with. Me? Not so much.

This is why the protocol book is more of a set of guidelines, not a Bible that must be adhered to.

(sneaky religious reference )

 

[18G]

In what way is the asymptomatic child in this scenario showing signs of heamodynamic compromise? Why does it need to be treated 'right then and there'?

I was referring to the scenario of this child (or any child) becoming unstable as was mentioned in the flow of conversation. I assume you recommend we allow adult patients with symptomatic SVT or VT remain in those rhythms because we are not physicians and "do not understand" and cannot "do medicine as well as a hospital"?

Anytime you encounter any patient who does not need immediate stabilisation, there are several good arguments for transporting them and not ing around on scene.

Of course. And this is a principle that we have ingrained in us and embrace from a very early stage as EMS providers. Nobody said anything about messing around onscene. It doesn't take all that long to start a line and give a med onscene or do it enroute.

It's also negligent to delay transport because you think you know what's indicated.

So Paramedics have no idea when treatments are indicated? We just blindly go around giving medicine and doing interventions without having a clue as to their indication? Really? No one is claiming to know everything or is asserting that Paramedics know as much as doctors. But we are more than capable of assessing a patient and knowing when something is indicated or not. To the accuracy of a physician? Of course not... that's why we consult with a physician from the field. However, it has been found that some Paramedics have 12-Lead skills that rival those of many physicians.

If a patient is presenting with a condition and meets criteria of a written medical protocol, you better have very good reason as to why you didn't follow it. There are few circumstances when an EMS provider should deviate from written medical protocol.

Having an unstable child in SVT and withholding treatment because your not a pediatric cardiologist and your only ten minutes away from a hospital is not a defense I would want to use in a case of negligence for withholding treatment. If it were my child and you did this, it would ring out to me that you were clueless and scared to treat my kid and wanted to take the easy way out. You better never let my kid suffer based on this irrationality. YOU DO NOT HAVE TO BE A PEDIATRIC CARDIOLOGIST TO GIVE ADENSOSINE!

I wholeheartedly agree that part of being a good practitioner is knowing when not to act or perform a skill, but when it is clearly indicated lets just do our jobs.

 

[Aidey]

I'm repeating myself to prove a point.

The pediatric physician can recognize WPW and the like.

WPW et al. first present most commonly under the age of 25. If I have someone under 25 in SVT who is stable, I am not giving them adenosine until I am confident beyond a doubt that it is a non WPW case. If they are unstable, well, why the heck are we using adenosine and not electricity?

As far as my doctor is concerned our protocols are guidelines. If I bring in a stable patient in SVT I'm going to have very little, if any, explaining to do.