Asymptomatic Pediatric SVT: Medicate or Wait?

[18G]

Even in the ED, how long are they gonna wait before they try a trial of adenosine? Chances are the ED will be pretty quick to try adenosine soon after arrival. The kid may be stable but I'm sure he/she probably feels kinda funny and not so good from having such a fast rate.

If we go head with the adenosine prior to arrival at the ED, we can one... slow the rate and fix the problem, make the kid and parents feel better.... or two.... realize the adenosine isn't working so as soon as we arrive we can relate to the ED staff that the adenosine didn't work and the ED can go to an alternate therapy or just wait it out.... hence saving time.

If i'm missing something about the safety profile of adenosine in kids someone please fill in the blanks for me.

 

[Veneficus]

Even in the ED, how long are they gonna wait before they try a trial of adenosine? Chances are the ED will be pretty quick to try adenosine soon after arrival. The kid may be stable but I'm sure he/she probably feels kinda funny and not so good from having such a fast rate.

I think the answer to this depends on what hospital you are at. If cardiology is readily available I don't think the ED is going to be overly quick on the trigger. If it is one of those community hospitals then they will probably follow into the ACLS cookbook and push it.

The thing is are you deciding to play around with some treatments you like or are you really serious about breaking the arrythmia?

In other words are you playing around, or really trying to help?

If we go head with the adenosine prior to arrival at the ED, we can one... slow the rate and fix the problem, make the kid and parents feel better.... or two.... realize the adenosine isn't working so as soon as we arrive we can relate to the ED staff that the adenosine didn't work and the ED can go to an alternate therapy or just wait it out.... hence saving time.

Saving time is not an indication for adenosine nor is it the purpose of EMS intervention.

If the adenosine doesn't work, how far are you willing to go in your treatment?

The ED is not definitive therapy. You don't see PCI or any number of treatments or dx performed there. Many times simply because they are not equipped.

The patient in the scenario is stable, with minimal symptoms/complaints. This is not an emergency. If I was going to take it upon myself to do something, it would be in the best interest of the patient, not because I could.

If i'm missing something about the safety profile of adenosine in kids someone please fill in the blanks for me.

Reported side effects include. (from my pharm quick reference guide)

Obviously it doesn't list the incidence of the side effects, but on the risk/benefit analysis, I would rather deal with the potential problems of this in a hospital in about 10 minutes than in the back of a truck because I could push the drug.

Cardiovascular
Facial flushing, headache, sweating, palpitations, chest pain,
hypotension, prolonged asystole, ventricular tachycardia, ventricular fibrillation, transient increase in blood pressure, bradycardia, atrial fibrillation, and Torsade de Pointes.

Respiratory
Bronchospasm, shortness of breath/dyspnea, chest pressure, hyperventilation, head pressure.


Central Nervous System
Seizure activity, including tonic clonic (grand mal) seizures, and loss of consciousness, lightheadedness, dizziness, tingling in arms, numbness, apprehension, blurred vision, burning sensation, heaviness in arms, neck and back pain

Gastrointestinal
Nausea, metallic taste, tightness in throat, pressure in groin.

 

[18G]

Perhaps I should have said, "increasing efficiency" instead of "saving time" although still somewhat synonymous. I agree the kid is not a critical patient where time is of the essence. But anytime we can increase efficiency and perhaps have a quicker resolution of someones problem... that is generally observed as a good thing.

I'm playing off both sides for sake of discussion and don't think either sides approach would have been wrong.

 

[Veneficus]

Perhaps I should have said, "increasing efficiency" instead of "saving time" although still somewhat synonymous.

But if they have to admit the kid for days, put him on a halter monitor, or induce an arrhythmia to diagnose whether the kid is a risk for SCD it doesn't save time or money compared to looking at him and the current EKG when he comes in.

Especially since his first EKG to compare is most likely the one EMS did in the field.

 

[Melclin]

1. Pick the kid up by the legs and dunk their head in a bucket of ice water.

2. *Guitar solo*

3. ?????

4. Profit.


B)

 

[SoCal]

Even in the ED, how long are they gonna wait before they try a trial of adenosine? Chances are the ED will be pretty quick to try adenosine soon after arrival. The kid may be stable but I'm sure he/she probably feels kinda funny and not so good from having such a fast rate.

If we go head with the adenosine prior to arrival at the ED, we can one... slow the rate and fix the problem, make the kid and parents feel better.... or two.... realize the adenosine isn't working so as soon as we arrive we can relate to the ED staff that the adenosine didn't work and the ED can go to an alternate therapy or just wait it out.... hence saving time.

If i'm missing something about the safety profile of adenosine in kids someone please fill in the blanks for me.

Another great post 18,

If there wasn't a funny feeling in this kids chest then he wouldn't have said anything to his parents and they wouldn't have taken him in. He didn't just take his pulse and say wow, 212, I should go tell my mom because that is outside my normal range. This kid is feeling symptoms, palpitations or otherwise.

Fix what you can, and honestly I feel like I got a complete paramedic education and to which I keep adding to by taking classes and following up on my pts. constantly learning, thanks for being concerned about my education though.

And by your guys' argument, if he does go into a rare dysrhythmia then you are only 10 min away from the hospital and it will be fixed like all of you are looking for the hospital to fix it anyways.

Once again I am just baffled reading some posts on this thread.

 

[WTEngel]

Have you fixed the problem?

The idea of pushing adenosine to "fix the problem" is a bit short sighted in my opinion.

First off, as others have stated, if you get no conversion with the adenosine, why stop there? Why not cardiovert? In for a penny, in for a pound, right? I don't see any reason why adenosine should be taken lighter than cardioversion. You are introducing a medication into the patient's body that will cause there heart to stop for a matter of seconds. Probably doesn't hurt as much as cardioversion, but still shouldn't be taken any more lightly.

Second, we must always remind ourselves to treat our patients, not the monitors to which they are attached. So, we have no hemodynamic compromise, patient is appropriately oriented, the only thing wrong at this point is a very squiggly line on a monitor that we simply don't like. We gain nothing by making that line a little less squiggly. The risk to benefit ratio just doesn't measure up in my mind.

Last, I would like to point out that in my experience (3 years working solely in critical care peds in addition to another 4 working 911 and flight) most of these cases will do one of two things: A, they self convert. This is ideal... B, they will become symptomatic. This really sucks, but those of you itching to fix something now have something to fix! Giving adenosine to a non symptomatic patient and causing them to develop symptoms leading to you cardioverting is never a good feeling...so don't go there. Allow the patient to self convert while en route to the hospital (highly likely) or closely monitor and prepare to act if symptoms develop.

Some people in this thread might not agree, but I stand by my original statement that you would be hard pressed to find a peds intensivist or cardio doc who would disagree.

 

[SoCal]

Last, I would like to point out that in my experience (3 years working solely in critical care peds in addition to another 4 working 911 and flight) most of these cases will do one of two things: A, they self convert. This is ideal... B, they will become symptomatic. This really sucks, but those of you itching to fix something now have something to fix! Giving adenosine to a non symptomatic patient and causing them to develop symptoms leading to you cardioverting is never a good feeling...so don't go there. Allow the patient to self convert while en route to the hospital (highly likely) or closely monitor and prepare to act if symptoms develop.

Once again another "roll the dice" kind of answer. :wacko:

 

[WTEngel]

Well then we agree to disagree.

If you think pushing adenosine is not a roll of the dice then you are mistaken.

You still haven't answered whether or not you would sync cardiovert this patient... And what would your reasoning be for not doing so?

 

[Akulahawk]

Once again another "roll the dice" kind of answer. :wacko:

Actually, not so much. Basically, if they appear to be compensating, let them be. Start a line, place the defib pads, perhaps have them do a valsalva maneuver, but otherwise, let 'em be. They'll spontaneously convert themselves or they'll start to decompensate. If the latter happens, well, you're already set up. At that point, the risk/benefit ratio swings in favor actively attempting to terminate the offending rhythm.

 

[SoCal]

Well then we agree to disagree.

If you think pushing adenosine is not a roll of the dice then you are mistaken.

You still haven't answered whether or not you would sync cardiovert this patient... And what would your reasoning be for not doing so?

1. I agree with that statement.
2. It is not rolling the dice, it is treating the patient who obviously is feeling something that he can't describe, but is affecting him.
3. In my protocols it only describes the indication for cardioversion reserved for hemodynamic instability, so if I gave him the adenosine and he became hemodynamically unstable, then yes I would, hands down.

If I gave him one dose and he didn't convert, then he gets the repeat dose.

 

[WTEngel]

It is rolling the dice... You have three possible outcomes. No change, conversion, or destabilization.

We have a patient in stable SVT, with no hemodynamic compromise. Adenosine will stop this patient's heart, in and of itself causing a hemodynamic compromise, possibly leading to a worsening of the patient condition, or possibly making it better... We have no idea of knowing. Roll of the dice, just the same as monitoring the patient for signs of instability will either see the patient improve, stay the same, or deteriorate.

The only difference in my eyes is that nothing I did to the patient had the possibility of making him deteriorate.

In a way you have changed the argument a bit. Are you saying that because the kid does have a funny feeling in his chest that he is for all intents and purposes symptomatic, and he should get the adenosine?

And last, but not least... What if your second dose of adenosine does not work? Do you consider cardioversion then? If your earlier argument still stands, you might as well cardiovert, bring the kid to the ER fixed, and save the ER the time and hassle of having to do it themselves...

 

[SoCal]

It is rolling the dice... You have three possible outcomes. No change, conversion, or destabilization.

We have a patient in stable SVT, with no hemodynamic compromise. Adenosine will stop this patient's heart, in and of itself causing a hemodynamic compromise, possibly leading to a worsening of the patient condition, or possibly making it better... We have no idea of knowing. Roll of the dice, just the same as monitoring the patient for signs of instability will either see the patient improve, stay the same, or deteriorate.

The only difference in my eyes is that nothing I did to the patient had the possibility of making him deteriorate.

In a way you have changed the argument a bit. Are you saying that because the kid does have a funny feeling in his chest that he is for all intents and purposes symptomatic, and he should get the adenosine?

Im not changing, I'm just offering a perspective that this pt. is symptomatic by what the OP said.

And last, but not least... What if your second dose of adenosine does not work? Do you consider cardioversion then? If your earlier argument still stands, you might as well cardiovert, bring the kid to the ER fixed, and save the ER the time and hassle of having to do it themselves...

Didn't think id have to say it again but, my protocols do not call for cardioversion in a pt who is not hemodynamically unstable. All I said is give the med. that you have for the problem.

Everyone is so focused on the bad side of what if, but what if you give the adenosine, he converts, feels relief, he's happy, parents are happy and you take him to the hospital fixed.

 

[18G]

Here is my thing with waiting. With kids, how do we know for sure how long they have been feeling the palpitations or other symptoms of the fast rate? If the child is out playing with their friends and the SVT isn't bad enough to cause them to stop playing right away, we could have a kid that has been in SVT for 2hrs before we get there.

Why should we "wait" for them to decompensate before we decide to do something as was suggested? We all know SVT is a common occurrence in kids, we know adenosine is a pretty safe treatment, we know its indicated, we know adenosine works really well in most cases and has a super-short half-life, and we have the option of consulting on-line control prior to giving it.

I don't believe that just because adenosine is given we should feel obligated to go to cardioversion. Explaining to a kid your gonna give them some medicine is much different than slapping two big patches on their chest with wires and telling them your gonna shock em! Even with sedation or analgesia I would imagine it would be pretty scary for them.

What is the percentage of kids that resolve on their own without intervention? I could not find any statistic on this only that most kids outgrow SVT as an occurrence.

How long is long enough to wait for kids to come out of SVT? 10mins? 30mins? two hours?

 

[reaper]

Do we know how long this child has been maintaining a rate of 210? This will not maintain forever. Just like any other muscle, it will start to wear down. With a child, we may not see this coming.

For me, I would want to know the extent of time that he has maintained at this rate. That will be a big factor in treatment decision.

 

[18G]

1) Adenosine will stop this patient's heart, in and of itself causing a hemodynamic compromise"...

2) "We have no idea of knowing"

3) The only difference in my eyes is that nothing I did to the patient had the possibility of making him deteriorate.

1) Adenosine does not always cause cardiac stand still.

2) Adenosine is a well studied medication and we do kinda know the outcome as a direct result of research and the fact that adenosine is a med given tons of times over with its effects and safe administration observed and recorded.

3) Withholding an antiemetic won't make someone deteriorate either but it's not best to withhold it. Not giving a narc to a patient with a fracture won't make em deteriorate either but its best not to withhold it.

Granted, giving a cardiac med is more involved than giving some Zofran, but I don't think that should take away from the principle which is to treat your patients within the realm of your protocols and use your training and education to provide relief and resolution of a patients problem. Yes, sometimes waiting is apart of that, but to go along with what a few are suggesting we may as well never treat anything as were rarely ever 100% sure given the field environment and scope of pre-hospital care.

 

[socalmedic]

there are many good arguments that i have read over the last few days. i feel most of them have great arguments as well. I tend to only treat symptomatic (ie, CP SOB) this is not because i am afraid of the drug, or having to cardiovert. it was explained to me a few months back by an interventional cardiologist while bringing in a false positive stemi (I am in the great MICN state of CA, what LP12 says must be true, but i conveyed that i didnt believe it), that if the patient is relatively stable (IE mild CP, mild SOB, sats stable, BP > 90) they want to see the patient before and durring conversion with a continuious 12 lead so that they can diagnose what the SVT is from and prevent it from reoccurring.

that may just be a regional thing but i understand where he was getting at. if i bring in an SVT patient they are always ready to receive them. i dont treat mild svt with anything, not even valsava. moderate SVT i consider treatment if i am more than 15min ish out. if they are unstable or very symptomatic they are getting electrical cardioversion, now.

this is just my way of treating them, i have not met an ED MD who has a problem with this.

my vote is for wait, my explanation is above.

 

[usalsfyre]

Didn't think id have to say it again but, my protocols do not call for cardioversion in a pt who is not hemodynamically unstable. All I said is give the med. that you have for the problem.

Everyone is so focused on the bad side of what if, but what if you give the adenosine, he converts, feels relief, he's happy, parents are happy and you take him to the hospital fixed.

First, you need to be able think outside your protocols, just because the book says "push adenosine" doesn't mean it's particularly appropriate.

Second, what's your downside of being conservative? A few minutes of the kid not feeling well? Versus the downside of treatment being death in the field where he has two to five providers to work the code instead of an entire resuscitation team.

 

[usalsfyre]

Why should we "wait" for them to decompensate before we decide to do something as was suggested?

We don't have to wait for them to fall off the cliff, but learn what to look for besides vital signs. Is the kid pale, cool or diaphoretic vs pink, warm and dry? Does he seem anxious? These are much earlier signs than a HR or B/P drop, and indicative of hemodynamic instability.

How long is long enough to wait for kids to come out of SVT? 10mins? 30mins? two hours?

It's a fairly safe bet outside of other comorbidities kids can remain stable for a long time in SVT. 80 year olds walk around in afib with RVR all the time. They will warn you they're getting unstable, but you've got to assess further than what the Lifepack tells you.

I've seen an emergency physician, a couple med students and a guy who has probably saw more sick kids in a week then most of us will see in a career recommend caution. Granted, it's easy to not be who you say you are over the internet, but these individuals also have constructive knowledge to add to a discussion far beyond what most paramedics have, so I'm inclined to believe them. The only reasons I've seen for treating have been "protocol" and "why not" both of which are pi$$ poor reasons for any medical care.

 

[SoCal]

The only reasons I've seen for treating have been "protocol" and "why not" both of which are pi$$ poor reasons for any medical care.

Not my point at all, I said treat because we are ALS providers with the knowledge about how this medication works and how the body works and can put the two together that this kid is feeling symptoms and is uncomfortable because of it and needs treatment. End of story. Yes my protocols back up my decision and like 18G said above, med-control is only a radio click away.

To defend my argument, I feel like running a code with my 3 to 6 providers is much more efficient and on point than a hospital, just from my experiences.

Most Dr.s I bring pts into, want to see our 12-lead, and most of the time we transmit it over bluetooth and they have it before we even arrive, so they can see what is going on and don't need to see this kid in SVT on their monitor.

Like ive said in my earlier posts, I offer my point of view, I am not saying any of these answers are wrong, just not my way of doing it.