3YO Male, Sick

Tigger

Dodges Pucks
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You're called to a pediatrician's office for a 3yo male "sick person, possible flu."

You find your patient in an exam room, seated with no assistance on the table. He tracks you as you walk in and interacts appropriately. You note his skin to be quite pale and he is on a simple mask at 4lpm. Though he appears tired, he still has normal strength throughout all extremities. Mom reports that she brought him today for flu like symptoms that have been going on for four days. Symptoms include a fever of 101.7, chills, and a productive cough. Mom reports that sometimes his coughs "sound just like a seal" but that this has not happened in several hours. Mom also relates some diarrhea over the past several days. She denies any medical history for the patient and states that she has been giving tylenol as directed for fever.

Out in the hall, you have a conversation with the pediatrician who reports that rapid flu and strep are both negative. She tells you that the patient was lethargic on arrival and hypoxic on arrival at 85% with increased work of breathing. With oxygen, the patient is satting at 95% with a good pleth and has only a minimal increase in work of breathing, his mentation has also improved. The doctor would like the patient transported to the local children's hospital, which is about 25 minutes away and also your closest facility. They are not able to acquire any lab work for you, though the doc states she is "concerned about leukemia."

Your assessment reveals the following:
Mental Status: Alert/Oriented, interacting in an age appropriate manner.
Skin: Pale, warm, dry.
HEENT: Pupils equal/round/reactive. Atraumatic. Neck supple.
Chest: Equal rise and fall bilaterally. Minor accessory muscle use noted. Rhonchus lung sounds noted in BL lower fields.
Abdomen: Soft, non-tender, non-distended.
Pelvis: Stable, non-incontinent.
Extremities: Good distal perfusion x4.
Neuro: No apparent deficits.

No signs of non-accidental trauma or anything like that. Mom is there and is very helpful with history questions. The patient appears well nourished and cared for.

Vital Signs:
HR: 245. You think you can feel a brachial and carotid but you can't count. Strip is below.
RR: 24, moderately labored.
BP: 90/40 (manual).
SpO2: 95% @ 4lpm
Temp: 101.7 temporal

Given that mom is there, you attempt IV access with her help in the office. Following two attempts for 24ga catheters in the hand and foot, you are not able to obtain an IV. There might be an EJ you can access with a 22 but the patient is quite difficult to keep still.

So now what? What's your treatment plan? How will you transport?
 

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PotatoMedic

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I have a sick patient, probably dehydrated, with a stable tachycardia. I'm going to plop him on my gurney and drive. I don't want to cardiovert without a line and would want to do fluids first before adenosine.

If he deteriorates I'll consider the ej but probably io the kid and treat as appropriate.
 

MEDicJohn

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Establish IV fluids for the dehydration. Keep both mom and child super calm no agitation. PREP a possible nebulized treatment and ET just as a last prep for the worst. Obviously continue to monitor enroute. Stable tachy is concerning
 
OP
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Tigger

Dodges Pucks
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Establish IV fluids for the dehydration. Keep both mom and child super calm no agitation. PREP a possible nebulized treatment and ET just as a last prep for the worst. Obviously continue to monitor enroute. Stable tachy is concerning
As stated, you are not able obtain PIV access on this patient. Maybe you could get an EJ. Big maybe.
 

Peak

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I think this becomes a question of how sick do you think the kid is. The presentation you describe isn't reassuring, but if he can make it 25 minutes without intervention that transport may he the best option. Likely he has been like this for hours or days.

I think this also depends greatly on skill level. I have zero problems placing an EJ in a toddler, but I've done countless on infants (and older patients). That being said most prehospital providers don't see a lot of peds, especially sick kids, so most likely most people considering this case would not be successful in accessing his EJ.

This kid obviously needs a full workup, but his hemodynamics are of immediate concern. A resting HR of 245 isn't normal even in the setting of mild fever, dehydration, and possible anemia. Even in infants a heart rate that high prevent adequate refilling of the heart and is detrimental to perfusion. Was there any variability to his HR? I do think that he needs SVT to be ruled out.

What is his BGL?

If he doesn't look stable he needs access, IO if necessary. If no concern for CHD or heart failure 20 CC/kg of an isotonic fluid bolus. Likely you would be at the hospital by this time but consider PALS algorhythm for SVT or other deterioration in cardiopulmonary status. Bonus to a bolus is you can plump up his veins for the hospital.

Dont delay transport for USGPIV or other such things, if he does end up having leukemia with a fever antibiotic and antiviral timing is going to be huge for his outcome. Work in the back of the bus.

If you have a very high suspicion for SVT you could try to pop him out with vagals.
 

PotatoMedic

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I think this becomes a question of how sick do you think the kid is. The presentation you describe isn't reassuring, but if he can make it 25 minutes without intervention that transport may he the best option. Likely he has been like this for hours or days.

I think this also depends greatly on skill level. I have zero problems placing an EJ in a toddler, but I've done countless on infants (and older patients). That being said most prehospital providers don't see a lot of peds, especially sick kids, so most likely most people considering this case would not be successful in accessing his EJ.

This kid obviously needs a full workup, but his hemodynamics are of immediate concern. A resting HR of 245 isn't normal even in the setting of mild fever, dehydration, and possible anemia. Even in infants a heart rate that high prevent adequate refilling of the heart and is detrimental to perfusion. Was there any variability to his HR? I do think that he needs SVT to be ruled out.

What is his BGL?

If he doesn't look stable he needs access, IO if necessary. If no concern for CHD or heart failure 20 CC/kg of an isotonic fluid bolus. Likely you would be at the hospital by this time but consider PALS algorhythm for SVT or other deterioration in cardiopulmonary status. Bonus to a bolus is you can plump up his veins for the hospital.

Dont delay transport for USGPIV or other such things, if he does end up having leukemia with a fever antibiotic and antiviral timing is going to be huge for his outcome. Work in the back of the bus.

If you have a very high suspicion for SVT you could try to pop him out with vagals.
Have any tips and tricks to share for pediatric EJ's? I keep joking I could stick it in my kinds neck but I also know how much he wiggles around and that is what would deter me.
 

E tank

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Have any tips and tricks to share for pediatric EJ's? I keep joking I could stick it in my kinds neck but I also know how much he wiggles around and that is what would deter me.
I got one, Spud...just get the kid to the hospital and don't even try...febrile, dehydrated kid with a HR of almost 300...flat veins and a jacked up mom? Askin' for trouble...
 
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Tigger

Dodges Pucks
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I got one, Spud...just get the kid to the hospital and don't even try...febrile, dehydrated kid with a HR of almost 300...flat veins and a jacked up mom? Askin' for trouble...
Mom was not jacked up at all. Quite helpful in fact when we tried foot and hand. He had a noticeable EJ while sitting up and while I wasn't about to stick it, it was a possibility. I've only done EJs in obtunded kids, I honestly do not think we could have kept him still enough.
 
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Tigger

Dodges Pucks
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I did not run this call but was present so I can't quite provide everything. I can tell you that his HR stayed between 240-245 for the duration. In the interest of keeping the patient calm following IV attempts, a BGL was not obtained which I guess could go either way. A 12 lead was not obtained either, nor was EtCO2 though realistically there was no way anyone could keep a cannula in his nose.

I am not sure what this rhythm is. I called it sinus tach initially as I think you can see P waves in some leads. But 245 seems awfully fast for a three year old. The children's hospital informed me that "it's fast so therefore it's SVT even if there are P waves." They planned to give a single dose of a beta blocker if the rate didn't come down...though the patients blood pressure was 70/40 when we left 30 minutes later.

I think a more interesting question is if this kid is obtunded, profoundly hypotensive, and hypoxic on O2, at what point if any are you concerned about the rhythm and its potential contributions to badness? If it is SVT as a PALS instructor, I am obligated to tell you to cardiovert (lulz), but I don't know if I believe that.
 
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PotatoMedic

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I got one, Spud...just get the kid to the hospital and don't even try...febrile, dehydrated kid with a HR of almost 300...flat veins and a jacked up mom? Askin' for trouble...
I was asking more outside of the scenario in general terms.
 

Peak

ED/Prehospital Registered Nurse
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Have any tips and tricks to share for pediatric EJ's? I keep joking I could stick it in my kinds neck but I also know how much he wiggles around and that is what would deter me.
Positioning and holding traction is huge. I have someone hold the head, someone hold the chest if needed, and someone apply pressure and pull traction on the proximal aspect of the EJ using the side of a tongue depressor. As kids get bigger or are more cooperative/sedated I can have one person hold the tongue depressor and I can hold proximal (meaning closer to the chest) traction with my middle finger and distal traction with my thumb.

Like all EJs but especially with kids catheter choice is key. I prefer a braun cath over a BD autogaurd as the back part doesn't become an issue with their jaw. I will sometimes bend the needle to help with that as well. On larger EJs I've found the nexiva caths to work well too.

A lot of it is just practice though.
 

Peak

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I did not run this call but was present so I can't quite provide everything. I can tell you that his HR stayed between 240-245 for the duration. In the interest of keeping the patient calm following IV attempts, a BGL was not obtained which I guess could go either way. A 12 lead was not obtained either, nor was EtCO2 though realistically there was no way anyone could keep a cannula in his nose.

I am not sure what this rhythm is. I called it sinus tach initially as I think you can see P waves in some leads. But 245 seems awfully fast for a three year old. The children's hospital informed me that "it's fast so therefore it's SVT even if there are P waves." They planned to give a single dose of a beta blocker if the rate didn't come down...though the patients blood pressure was 70/40 when we left 30 minutes later.

I think a more interesting question is if this kid is obtunded, profoundly hypotensive, and hypoxic on O2, at what point if any are you concerned about the rhythm and its potential contributions to badness? If it is SVT as a PALS instructor, I am obligated to tell you to cardiovert (lulz), but I don't know if I believe that.
Depending on the rate and location of the re-entry node or ectopy center you can potentially see p waves in SVT, retrograde from the preceding complex. We especially see this in JET but can be seen in WPW and other SVT rhythms. Since kids can have pretty significant cardiac rotation without historic normal EKGs it is difficult to determine retrograde p waves in tachycardia.

I would establish venous access and give a dose of adenosine. I don't think it is unreasonable in these kids to place an IO if necessary to give fluids so that you can place an IV, and optimizing fluid balance will help to convert them out too (with preference given to plasmalyte or LR, but saline need not be excluded). Given some fluids and some oxygen if a patient breaks with adenosine and quickly goes back in then cardioversion is unlikely to bring any more benefit, but I wouldn't advise against the PALS pathway in the field.

If we dont break them then we will typically start a beta blocker, then amio, and then consider a sodium channel blocker. On occasion we can break them with a beta and then giving adenosine or cardioverting, but this should only be done in a cardiac PICU.

Kids with refractory SVT should be transferred to a ECMO center, which unfortunately that hospital is not.

Also a lot of people get hung up on giving agents that typically associated with hypotension to these patients. They have such poor atrial and ventricular filling that more often than not giving them that time to fill benefits their pressure more than the agent itself decreases pressure.
 
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akflightmedic

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Can anyone educate me on why an EJ is even being discussed to this extent? I would just go IO and be done with it. Is there an obvious pro to the EJ over the IO relevant to this scenario that I am not picking up on prior to my coffee?
 

PotatoMedic

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Can anyone educate me on why an EJ is even being discussed to this extent? I would just go IO and be done with it. Is there an obvious pro to the EJ over the IO relevant to this scenario that I am not picking up on prior to my coffee?
I would say that there isn't anything special about doing an ej vs an io. I just was curious if there was any special advice for doing them on a pediatric. But as I said initially, I'd probably look for one if the kiddo deteriorated for about two seconds.
 

VFlutter

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Can anyone educate me on why an EJ is even being discussed to this extent? I would just go IO and be done with it. Is there an obvious pro to the EJ over the IO relevant to this scenario that I am not picking up on prior to my coffee?
Assuming pediatric would be a Tibial or Distal Femur IO so the flow rate and time to central circulation isn't all that great compared to an EJ PIV which means medications like Adenosine may be more likely to be effective with the latter? Just a guess
 

GMCmedic

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I think an IO is perfectly acceptable here. This kid needs fluid which may help the heart rate, but at the very least itll plump up the veins for better access if you need to go to adenosine (Im not convinced that you would). Im by no means a pediatric expert, but Im not to sure id transport without some sort of access.
 

Peak

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An IO is not an appropriate site for adenosine administration, an EJ can be.

I think that many members of the medical community be it EMS, ED, or ICU staff forget than IOs are not a guarantee. Patients could have a history of OI or other wise have brittle bones that result in fracture even with the EZ IO product. Many kids end up with the needle going through the backside of the bone, and patients of all ages end up with oval shaped entrances either from the insertion or the needle inadvertently being moved back and forth during use.

I have seen many kids who as a result or technique and/or confounding history have had two or three failed IO attempts by EMS and OSH EDs.

I don't think that IOs are without merit, but they do have limitations just like any other form of access.
 

E tank

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I'm not seeing the urgent need for an IV right then and there. And I would not make any attempt at getting that HR down other than giving fluid (if fortunate enough to have an IV) Are folks really thinking about intervening on that?
 

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