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TACHYCARDIA

how to keep your patient


alive in the middle of the night
Brenna Benson, PGY-2
2/27/2019
Parameters, in Pediatrics
PICTURE THIS…
It’s 0230.
Picture You are 19.5 hours into your Lahey shift and have just eased yourself
this…
between the scratchy sheets on the nice Styrofoam cot in the call room. Even the
NICU mom playing Candy Crush with the sound on next door can’t keep you awake.
As you start to drift off to sleep…..
4314, pt HR 150s. –RN
Patient

• 8 year old female with AML in induction, about 1 month in to


treatment
• She has been doing well over the last couple days, with no events
to report
• Her sign-out was that she had intermittent mildly elevated HR up
to the 130s, but that it was thought to be secondary to
deconditioning and that she otherwise looked great
You call RN back…

What do you want to know?


OTHER VITALS EXAM OTHER INFORMATION

• Febrile • Mental status most important to start • Fluid balance for the shift
• Tachypneic • Any cardiac monitor abnormalities
• Complaining of pain • Comfortable
• Hypotensive • In distress Chart review!
• Sleepy/asleep • Is this new for the patient
• What changes were made today
• Unresponsive • Recent medications
(You would hope this wouldn’t just be a page…)

• Capillary refill
• Pulses
• respiratory status
• What is the RNs overall perception of the
patient

You call RN back…


What do you want to know?
1. Make sure patient is stable: classify the
tachycardia

NARROW COMPLEX? WIDE COMPLEX?

Grab your
P waves? PALS card and
call for help!
2. Make sure patient is stable: what is the
hemodynamic status?

• SHOCK VERSUS NOT SHOCK


• COMPENSATED VERSUS UNCOMPENSATED
• ALWAYS CHECK
• blood pressure
• cap refill
• Pulses
• neuro status
Differential for Tachycardia (It’s a long list!)

CV- arrhythmias (multiple), myocarditis, pericardial


effusion, hypovolemia, anaphylaxis
RESP- Respiratory distress, pneumothorax, hypoxemia
FEN- Electrolyte derangements (multiple), dehydration
GI- Intraabdominal processes
HEME- anemia, PE
ID- fever, sepsis
ENDO- abnormal hormone levels (hyperthyroidism,
pheochromocytoma)
NEURO- seizures
PSYCH- Anxiety, excitement, pain
CAFFEINATED NERVOUS ANEMIC RIGORS
MEDS- caffeine, albuterol, toxins, cough and cold meds
Back to your patient…
• You go see her and she is sitting up in bed, eating a
cheeseburger, watching a movie, and in no distress
• T 37.2 HR 156 RR 28 BP 92/63 SO2 97% on RA
• CV: Tachycardic, RRR, no murmurs or gallops. Cap refill ~1
second centrally and peripherally. Strong pulses
bilaterally
• RESP: Mildly tachypneic but comfortable work of
breathing. Lungs clear bilaterally without wheeze,
crackles, or diminished breath sounds
• HEENT: Unremarkable
• GI: Mildly distended but soft and non-tender to palpation
• EXT: Non-edematous, warm and well-perfused
• NEURO: Awake and asking you to move so she can see her
movie
She has had an MSSA
I/O: Net negative 2 L No new meds
intrarenal abscess,
over the last three and no
s/p drainage, with
days. UOP and SOP Tylenol since
improving CRP and
normal yesterday
no fevers for days

Chart review…
To bolus or not to bolus?

• This patient: Well-appearing, afebrile, tachycardic child with net


negative fluid balance
• In considering a bolus, ask yourself:
• Is there another explanation for the tachycardia?
• Heart problems or potential for heart problems? Hepatomegaly? Rales?
• Is the patient on oxygen/do their lungs sound clear?
• Any recent boluses?
• How do the most recent electrolytes look?
• Are they on any medications that could be causing the net negative fluid
balance? (i.e. diuretics)
We give 1 20 cc/kg bolus

• HR slowly improves to 130s


• Exam unchanged otherwise, and lungs remain clear
• 1 hour later….
S/p 20 cc/kg bolus

• HR slowly improves to 130s


• Exam unchanged otherwise, and lungs remain clear
• 1 hour later….
• T 37.3 HR 162 RR 32 BP 92/62 SO2 96% RA
• She is now sleeping but awakens appropriately to exam and pushes you
away
• Pertinent exam findings:
• Tachycardic with RRR, no murmurs or gallops. Capillary refill ~1 second with
strong pulses; warm and well-perfused
• Tachypneic, no increased WOB, clear lung fields bilaterally
• Abd distended and soft, unchanged
• The rest of the exam is unchanged
Tachycardia Work-up

• CV: CXR, EKG, BMP, echocardiogram, lactate, BNP, troponin


• RESP: CXR, CT, D-dimer
• FEN: BMP, iCa
• GI: KUB, US, CT
• HEME: CBC, PT/PTT, INR
• ID: CBC, CRP, RFA, fungal markers, procalcitonin, imaging,
cultures, GI PCR, UA, LP
• ENDO: TSH/T4
• NEURO: CT, EEG
What do you want to do?

Labs?
Imaging?
Other diagnostic studies?
Meds or other interventions?
Re-examination?
2nd and 3rd 20 cc/kg boluses given= 60 cc/kg total for HR up to 170s

CV: CXR, EKG, BNP, CG8, echo

• All normal, except….lactate 4.7  6.4  9.8

RESP: D-dimer 558 CT angio normal

FEN: Electrolytes normal with anion gap 17 and BD 8; net negative fluid
balance prior to boluses

Next Steps GI: Abdominal girth slightly increased. LFTs normal. KUB, abdominal US
normal

over the next 6ish hours RENAL: BUN/Cr wnl and stable; normal UOP. Abscess improving in size on
imaging

HEME: CBC stable, coags normal

ID: Afebrile, but obtained CBC/CRP

• CBC stable
• CRP 1.8 (decreased from two days prior)
• Broadened antibiotic coverage

NEURO: Awake and alert. No pain


Next Steps, continued…

Decided to send
Huddled with
patient to the PICU
Fellow contacted PICU contacted bedside RN and
with significantly
charge RN
elevated lactate
CV: Trended lactates

RESP: Placed on O2 for shock protocol

FEN: 1.5x mIVF

In the PICU… GI: MRI abd/pelvis

ID: Blood cultures, UA with cultures, fungal


markers, continued broad spectrum antibiotics

NEURO: No concerns
MRI Abd/Pelvis:

1. Much decreased size of left renal abscess. There is also less


adjacent inflammation in the surrounding soft tissues of the
retroperitoneum, including the psoas muscle.

2. No new abnormality.
Before coming back to the floor….

CV: Received total of 100 cc/kg fluids. HR 170s140s prior to transfer


back to floor. Lactate 9.84.7
Resp: O2 removed in the morning
FEN: Back to 1x maintenance in the morning. Electrolytes all normal.
GI: Abdomen remained distended but soft and unremarkable
Heme: Gave 10 cc/kg pRBC (Hgb >8)

ID: Remained afebrile. Blood culture remained negative and UA


normal. Fungal markers, PCT normal; CRP improving
The next day….
The next day….

Worse abdominal distention and increased girth with increased WOB. Lactate 4.75.6. HR 150s
CXR normal
KUB IMPRESSION:
Findings compatible with marked distention of the stomach,
with ingested material and small amounts of gas.
Gastric distention was also noted on 10/20,
but was not noted on abdominal MRI dated 10/25/.
The findings raise the possibility of intermittent gastroparesis.
The next day…

• Anderson placed to LIS with improvement in distention


• 20 cc/kg bolus given with transient improvement in HR, which
then was back in the 140s
• Was well-appearing, so was monitored one more night
And finally….

• HR 130s, normal exam, lactate 3.5 two days prior to


discharge (stopped checking)
• Tolerating PO
• Sent home!
Key Points….

• Always go assess the patient


• Address hemodynamic status and rhythm strip before diving into
full differential
• Think by systems and what is most dangerous first
• Stepwise approach to differential
• Never be afraid to ask for help!
References

Brenna Benson’s personal experiences on the Lahey team (whatever that’s worth)

UptoDate
PALS
AHA guidelines