Pediatric Advanced Life Support - PALS Core Testing Case Scenario 11: Wide-Complex Tachycardia (Possible Ventricular Tachycardia) (Child unstable)

Scenario Lead-in

Prehospital:You are en route to a house where a 10 year old child has acutely developed difficulty breathing.

ED:You are called to the emergency department to help out when a 10 year old child is brought in after acutely developing difficulty breathing.

General Inpatient Unit:You are called as a member of the rapid response team to see a 10 year old child who acutely developed difficulty breathing.

ICU: You are called to see a 10 year old child who was admitted to the intensive care unit for a syncopal episode earlier in the day; he is now having acute difficulty breathing.

Vital Signs:

Heart Rate185/min

Blood Pressure74/35 mm Hg

Respiratory Rate46/min

SpO282% on room air

Temperature37.6C (99.7 F)

Weight30 kg

Age10 years

Scenario Overview and Learning Objectives

Scenario Overview: Emphasis should be on diagnosis and management of unstable wide-complex tachycardia to convert the rhythm and improve systemic perfusion and hemodynamic function. This is accomplished immediately with synchronized cardioversion. If functional intravenous IV/ intraosseous IO access has been established or can be established immediately and expertise is available, sedation may be provided. However, synchronized cardioversion should not be delayed. Providers should also search for and treat reversible causes. Expert consultation is advised. Administration of adenosine or other antiarrhythmics is beyond the scope of this scenario, but discussion regarding indication for adenosine and vagal maneuvers will verify student familiarity with treatment of other tachycardias with a pulse (eg, supraventricular tachycardia (SVT) with a pulse and adequate perfusion)

Scenario-Specific Objectives

Differentiates between narrow-complex (likely SVT) and wide complex tachycardia/possible ventricular tachycardia (VT) with a pulse and poor perfusion.

Differentiates between pulseless VT and wide-complex tachycardia (possible VT) with a pulse

Describes the indications for synchronized cardioversion for wide-complex tachycardia with a pulse and poor perfusion; in this scenario, the child demonstrates hypotension, acutely altered mental status, and signs of shock-these are indications for immediate synchronized cardioversion

Demonstrates safe delivery of synchronized cardioversion with appropriate shock dose in a patient with wide-complex tachycardia with a pulse

Describes the reason for caution and need for expertise when considering giving sedative before cardioversion for a child who has tachycardia with a pulse and poor perfusion

Evaluate - Initial Impression (Pediatric Assessment Triangle)

Appearance: Lethargic; opens eyes to voice but not talking spontaneously

Breathing: Spontaneous; rapid rate; significant retractions; grunting

Circulation: Pale; mottled

Identify:

No immediate intervention needed

Intervene:

Activate the emergency response system. Emergency medical services request additional assistance if needed.

Administer 100% oxygen by nonrebreathing face mask.

Apply cardiac monitor or monitor/ defibrillator.

Apply pulse oximeter.

Evaluate - Primary Assessment

Focused on Assessment Needed to Support Airway, Oxygenation, Ventilation, and Perfusion

Airway: Clear

Breathing: Respiratory rate 46/min; Spo2 82% (improves to 94% with 100% oxygen via nonrebreathing mask); subcostal and intercostal retraction; nasal flaring

Circulation: Heart rate 185/min; blood pressure 74/35 mm Hg; central pulses weak, peripheral pulses very weak; cool peripherally; capillary refill 4-5 seconds

Disability: Opens eyes to voice; intermittently moaning

Exposure: Temperature 37.6 C (99.7 F);

Weight: 30 kg

Identify:

Altered level of consciousness

Wide-complex tachycardia, possible VT, with a pulse and poor perfusion

Participant may also note

-Respiratory distress vs respiratory failure

-Hypotensive shock

Intervene:

Obtain vascular access (IV/IO), but do not delay cardioversion

Deliver synchronized cardioversion as soon as monitor/defibrillator arrives:

-If functional IV/IO access and expertise is immediately available, provide sedation if it won’t delay cardioversion. Use caution; expertise is required to avoid worsening hemodynamic instability.

-Attach pads and begin recording rhythm strip

-“Clear” and perform synchronized cardioversion (0.5-1 J/kg).

-If Initial synchronized cardioversion is unsuccessful, immediately “clear” and perform synchronized cardioversion with 2 J/kg.

Evaluate - Secondary Assessment

Identify Reversible Causes, but Defer Remainder of Secondary Assessment Until Rhythm Conversion

SAMPLE history (review with parent/primary caretaker only to identify reversible causes)

Signs and symptoms: Developed acute shortness of breath and difficulty breathing; no chest pain; no recent illnesses

Allergies: None

Medications: None

Past medical history: Fractured clavicle at age 6

Last meal: Supper with family

Events: Sudden shortness of breath and difficulty breathing

Physical examination if cardioversion correctly performed

Repeat vital signs post cardioversion: Heart rate 124/min; sinus rhythm; respiratory rate 28/min; Spo2 97% with 100% oxygen via nonrebreathing face mask; blood pressure 105/78 mm Hg

Head, eyes, ears, nose, throat/neck:Clear; no abnormal audible breath sounds

Heart and lungs: No murmur, gallop, or rub; subcostal and intercostal retraction less pronounced; breath sounds equal bilaterally; no wheezes or crackles; central pulses now strong; peripheral pulses; capillary refill 3 seconds.

Abdomen: Nondistended; nontender; no masses; normal bowel sounds

Extremities: Warm

Back: Normal

Neurologic: Pupils equal and reactive; now opens eyes and moves all extremities spontaneously; answers healthcare providers’ questions

Point of care glucose: 88 mg/dL

If no cardioversion

Vital signs: Heart rate 185/min; blood pressure 68/33 mm Hg; worsening perfusion (weak central and very faint peripheral pulses); capillary refill 6-7 seconds

Identify

Altered level of consciousness

Wide complex tachycardia (possible VT) with a pulse and poor perfusion converts to sinus rhythm if synchronized cardioversion provided correctly

Respiratory failure

Intervene

Obtain expert consultation.

Search for and treat reversible causes.

After rhythm conversion

-Reassess and monitor cardiorespiratory status.

-Evaluate for signs of heart failure (enlarged liver, extra heart sounds or murmurs, crackles)

-Assist ventilation with bag mask device if needed.

-Wean supplementary oxygen as tolerated if child remains stable after cardioversion.

-Obtain 12 lead electrocardiogram (ECG).

-Check glucose with point of care testing.

Evaluate - Diagnostic Assessments

Perform Throughout the Evaluation of the Patient as Appropriate

Lab data

Blood glucose: 88 mg/dL

Electrolytes

A blood gas (arterial, venous, or capillary blood gas) and electrolytes not indicated in the immediate management of this child, but could be considered after stabilization to guide further management

Imaging

Chest x-ray (evaluate for cardiomegaly, pulmonary edema, or effusions)

Repeat ECG

Identify/Intervene

Although laboratory tests are generally not appropriate during the immediate management, a blood glucose concentration should be checked as soon as reasonably possible in all critically ill infants and children. Hypoglycemia should be treated immediately.

Serum electrolytes should also be checked as soon as possible. An electrolyte abnormality such hypokalemia or hyperkalemia may cause ventricular arrhythmias.