Asymptomatic Pediatric SVT: Medicate or Wait?

[18G]

How would you answer a prosecutor if they asked you these questions for failing to treat and something bad happened as a result?

Why didn't you follow your medical protocol and treat the child who met the criteria?

Does your protocol allow for provider discretion to not treat patients when they meet criteria and to deviate on your own from standard protocol?
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I think these are two very important questions. The majority seem to want to make the decision to hold off on there own without medical control consultation which I think is a bad idea. If your gonna stray than consult. I don't think there is any real good answers to the above questions when you intentionally do not follow protocol and do not consult with a doctor.

The majority are using the argument that we as Paramedic's do not have the education to make the decision to treat pediatric SVT, yet the same majority is claiming to have enough education on their own to make the determination not to treat based on their great understanding of SVT. How can you do one and not the other?

If we do treat, we are treating based on a standardized criteria and standing order that was written by physicians. If it was such a bad idea and a high risk treatment than why is is so standard?

 

[18G]

Adenosine and pediatric supraventricular tachycardia in the emergency department: multicenter study and review.
Losek JD, Endom E, Dietrich A, Stewart G, Zempsky W, Smith K.

Children's Hospitals and Clinics, St Paul, MN, USA.
Abstract
STUDY OBJECTIVE: To determine the frequency of successful cardioversion and the adverse effects of adenosine treatment in pediatric emergency department patients with supraventricular tachycardia (SVT).

METHODS: This was a multicenter descriptive study with both prospective (convenience sample) and retrospective (chart review) patient entry. The setting was 7 urban pediatric EDs with a yearly census range of 22,000 to 70,000 visits. Pediatric patients 18 years of age and younger who received intravenous adenosine for presumed SVT were eligible.

RESULTS: Six investigators from 7 pediatric EDs entered 82 patients with 98 presumed SVT episodes (52 prospective and 46 retrospective) into the study. Twenty-five episodes occurred in children younger than 1 year of age. Eight patients had congenital heart disease, 59 had a history of SVT, 43 were taking cardiac medications (digoxin in 27), 13 had a history of asthma, and 25 presented in compensated cardiogenic shock. A total of 193 intravenous doses of adenosine were administered; doses were classified as low (<.1 mg/kg [n=18]), medium (.1 to <.2 mg/kg [n=116]), or high (>/=.2 mg/kg [n=59]). The dose range was.03 to.5 mg/kg, and only 2 doses were higher than.3 mg/kg. A total of 95 patient-events were determined to be SVT, all but 5 of which were atrioventricular (AV) node-dependent; 3 events were ventricular tachycardia. The overall cardioversion success rate of adenosine was 72% (71/98), and that for AV node-dependent SVT was 79% (71/90). Cardioversion was successful for 4 patient-events at a low dose, 44 at a medium dose, and 23 at a high dose of adenosine. Adverse effects occurred in 22 patients, and no patient had bronchospasm or hemodynamically significant arrhythmia.

CONCLUSION: Intravenous administration of adenosine led to successful cardioversion in 72% of pediatric ED patient-events that were presumed to be SVT. A dose range of.1 to.3 mg/kg was found to be most effective. Adenosine was not associated with significant adverse effects.

 

[Shishkabob]

Does your protocol allow for provider discretion to not treat patients when they meet criteria and to deviate on your own from standard protocol?

Actually, your protocols might not, but mine do.


Quoted from protocol book:

It is incumbent on the prehospital clinician to understand that these clinical practice guidelines and policies can only provide guidelines for patient care. The very nature of critical and emergency care delivery outside the walls of a hospital demand some level of autonomy and flexibility. Clinician experience and judgement should be utilized to assure the best patient care

Oher protocols I've seen state the same thing: Protocols do not take the place of sound clinical judgement.

Essentially, "if you can defend it, you can do it"

 

[18G]

Mine do say a similar thing but they also say when you choose not to follow a protocol you need to consult with medical control.

Again, a majority is saying we don't have the education to make sound decisions but yet we can deviate from medical protocol? I'm not following. You can't have it both ways.

 

[usalsfyre]

How would you answer a prosecutor if they asked you these questions for failing to treat and something bad happened as a result?

Simple, the child while in my care was hemodynamicly stable, had no findings consistent with imminent decompensation and in my clinical judement it was best to wait until more resources were available to treat their condition.

I in return ask this, how would you answer to a plaintiff's attorney if you treated a stable, hemodynamicly stable patient with no complaints other than a "fluttering" and it went go bad?

Legally if this case goes bad your screwed either way, so forget that argument. Not to mention I HATE when providers try to use the legal system to jack the argument in their favor instead of relying on sound clinical judgement and what's good for patient care.

 

[usalsfyre]

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.

Describe to me in detail pediatric SVT including cardiac conduction, accessory pathways, how cardiac output is affected ect. Got that? Good now describe adenosine, how it' metabolized, it's method and duration of action (at the cellular level) how it's excreted, ect. On the fly, not using the internet.

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.

If you truly believe this you either 1). bring the patients to REALLY crappy EDs (not ruling this out, I've seen some really, really bad ones) or 2). have no clue what your watching and think running down an ACLS algorithm is all that's need for an arrest.

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.

Agreed, but it's not about the physician seeing the condition. It's about the resources available to treat it.

 

[Veneficus]

How would you answer a prosecutor if they asked you these questions for failing to treat and something bad happened as a result?

Doubt very much I would be answering to a procecutor, perhaps a plantif attorney. If the kid got worse from the presentation depending on how worse, would determine if I went with adenosine or cardioversion. Since the cardioversion is the elective treatment, as well as the most potent indicated for the life threatening presentation, it should work where adenosine would fail.

"In my medical opinion, at the time of presentation, adding a chemical to stop the pts heart was not indicated. When it was apparent intevention was required, I performed the indicated intervention."

Why didn't you follow your medical protocol and treat the child who met the criteria?

Because I don't have a protocol for it and the child did not present needing immediate intervention.

Does your protocol allow for provider discretion to not treat patients when they meet criteria and to deviate on your own from standard protocol?

At current, I have only to convince the attending overseeing me (who is usually only a few feet away) of my findings and treatment plan, I have yet to be denied. However, when I worked in EMS I always had a protocol that permitted sound clinical judgement in deciding to administer treatment and which ones.
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I think these are two very important questions. The majority seem to want to make the decision to hold off on there own without medical control consultation which I think is a bad idea. If your gonna stray than consult. I don't think there is any real good answers to the above questions when you intentionally do not follow protocol and do not consult with a doctor.

What are you hoping the doc will tell you over the phone? There are only 2 options, give the adenosine and hold off. As I said before that decision will be made by liberal or conservative opinion of the doc you reach. You could ask 10 docs and get 11 different answers. But I gave my opinion if I was the doc in charge already. (I get to dress up and play doctor 6 days a week)

The majority are using the argument that we as Paramedic's do not have the education to make the decision to treat pediatric SVT, yet the same majority is claiming to have enough education on their own to make the determination not to treat based on their great understanding of SVT. How can you do one and not the other?

I think because the people arguing it are not the average paramedics as seen in the US in my experience. Once you start adding other medical or healthcare education to the 750 hours of paramedic vocational education, you get people who are more likely to use more information when making their decisions. As you can see from the discussion, there is more to it than "that is what the protocol said."

Several explanations that incorperate "sound clinical judgement" were put forth. It is not that I cannot be persuaded, it is that it takes some reasoning other than a protocol that is written for a majority of situations or this medication is "usually safe."

Do you "make people fit" when they present in a way that the protocol was not written for?

Considering the effectiveness of many EMS protocols and interventions, I hold them all suspect. I have finally made it to the point in my education where my independant judgement is being guided by the more experienced. I am not blindly following orders. When I have a question I also get a better answer than "the protocol says" or an assumption of usually.

If we do treat, we are treating based on a standardized criteria and standing order that was written by physicians. If it was such a bad idea and a high risk treatment than why is is so standard?

Do you think physicians have some absolute knowlege? Do you think the protocols fit every patient? Is there a protocol for every patient?

I think they have written guidlines that require some judgement.

It is not that I think adenosine is extremely high risk, I have pointed out the risks as well as the course of the patient's likely future in the hospital. In the risk/benefit and aggresive/conservative intervention I determiine this patient to fall into wait and watch. That is a accepted standard of care in many presentations of many diseases. (obviously not all)

Adenosine and pediatric supraventricular tachycardia in the emergency department: multicenter study and review.
Losek JD, Endom E, Dietrich A, Stewart G, Zempsky W, Smith K.

Children's Hospitals and Clinics, St Paul, MN, USA.
Abstract
STUDY OBJECTIVE: To determine the frequency of successful cardioversion and the adverse effects of adenosine treatment in pediatric emergency department patients with supraventricular tachycardia (SVT).

Fail

METHODS: This was a multicenter descriptive study with both prospective (convenience sample) and retrospective (chart review) patient entry. The setting was 7 urban pediatric EDs with a yearly census range of 22,000 to 70,000 visits. Pediatric patients 18 years of age and younger who received intravenous adenosine for presumed SVT were eligible.

RESULTS: Six investigators from 7 pediatric EDs entered 82 patients with 98 presumed SVT episodes

Not exactly statistically powerful. Who even bothered to publish this and why?

(52 prospective and 46 retrospective) into the study. Twenty-five episodes occurred in children younger than 1 year of age. Eight patients had congenital heart disease, 59 had a history of SVT, 43 were taking cardiac medications (digoxin in 27), 13 had a history of asthma, and 25 presented in compensated cardiogenic shock. A total of 193 intravenous doses of adenosine were administered; doses were classified as low (<.1 mg/kg [n=18]), medium (.1 to <.2 mg/kg [n=116]), or high (>/=.2 mg/kg [n=59]). The dose range was.03 to.5 mg/kg, and only 2 doses were higher than.3 mg/kg. A total of 95 patient-events were determined to be SVT, all but 5 of which were atrioventricular (AV) node-dependent; 3 events were ventricular tachycardia. The overall cardioversion success rate of adenosine was 72% (71/98), and that for AV node-dependent SVT was 79% (71/90). Cardioversion was successful for 4 patient-events at a low dose, 44 at a medium dose, and 23 at a high dose of adenosine. Adverse effects occurred in 22 patients, and no patient had bronchospasm or hemodynamically significant arrhythmia.

That is an adverse effect in 26% and not properly described. Not exactly a glowing endorsement.

CONCLUSION: Intravenous administration of adenosine led to successful cardioversion in 72% of pediatric ED patient-events that were presumed to be SVT. A dose range of.1 to.3 mg/kg was found to be most effective. Adenosine was not associated with significant adverse effects.

The numbers I have seen is as high as 80%, but that still leaves 1/5 that are not successful. In this study, we could stipulate 1/4 But I am certainly not making a practice decision on 82 patients in an ED. What did Peds cardio see? That will add in IFT patients and over a larger time period as well as alternative interventions.