2. “The patient is greater than 1 week old, so the diagnosis cannot be a ductal-dependent CHD. The DA should have closed days ago.” Patients with ductal-dependent cardiac disease, especially ductal-dependent systemic blood flow, may have persistence of DA patency beyond 24 hours of life as a result of increased DA blood flow. Cardiovascular collapse in a child less than 1 month of age should be considered as a CHD with ductal-dependent systemic blood flow until proven otherwise.

3. “The infant is febrile. We should evaluate and treat for sepsis. CHD is not likely.” While sepsis is more common and should be suspected in any neonate presenting to the emergency department with tachypnea, cyanosis, or shock, a diagnosis of CHD should not be excluded based solely on the presence of fever. In fact, the presentation of a patient with CHD may be precipitated by an infectious process.

4. “The blood pressure and SpO2 obtained in triage are normal. I’m reassured.” Infants presenting to the emergency room in distress should have blood pressure and SpO2 measurements performed on the right upper extremity and one lower extremity. A discrepancy between the two extremities is suggestive of CHD.

In the June 2008 issue, Drs. Subramanian and Bray discuss the diagnosis and management of wide complex tachycardia in the ED. It is an excellent summary of the available evidence; the article lays out a step-by-step process to approaching this complex problem.

I would just like to add my paradigm, which was created with the thinking that if you have an opportunity to reduce your cognitive load, always take it.

• Unstable is easy–shock
• If they’re stable and the rhythm is fast (>200 bpm), wide, and irregular; assume WPW with antidromic conduction/atrial fibrillation: give procainamide (or if you’re familiar with it, ibutilide)
• If they’re stable with a WCT and none of the above, give amiodarone.
• If it starts to look like TdP or the patient is not getting better, try some Bicarb

They’re you go, basically an acerebrate approach, but you’ll rarely get burned. Now the clever reader may say that this algorithm can be further reduced to shock unstable rhythms and give amio to everyone else and the ACLS guidelines will agree with you. However, there is a small literature out there saying that amiodarone may not be a clever choice for antidromic WPW.

See:
Can J Emerg Med 2005;7(4):262

Certainly not definitive, but makes you think. Perhaps, the authors can comment?

In the May 2008 issue of Emergency Medicine Practice, , Dr. Ethan Booker provides an excellent review of the management of severe sepsis and septic shock. He brings up the value of ScvO2 to diagnose tissue hypoperfusion., even in the face of a good blood pressure and adequate CVP.  The ScvO2 can be obtained by drawing a blood gas from the distal port of your neck central line; make sure to draw up 3-5 ml of blood and discard, before drawing the gas. ScvO2 can detect occult shock in other conditions besides sepsis, though the literature is not as robust. A low ScvO2 (<70) should make you wary that the tissues might not be receiving enough oxygen.

The author points out that the value of CVP as a marker of  inadequate fluid resuscitation is debatable. The study he cites showed very little utility to using CVP for this purpose. However, the population in the study were ICU patients already past their resuscitative phase. The ED population is very different; often, we will get a CVP when the patient is still under-resuscitated. I often obtain CVPs of 1-2 mm HG on patients with severe sepsis and septic shock at the beginning of their treatment. These values almost always indicate the need for fluid resuscitation. Resuscitating from these low levels to the 8-12 recommended in the sepsis guidelines will rarely lead to too much fluid and in fact may under-estimate the volume needs of your patient.Until better measures come to the ED, CVP is essential to treat these patients, even if the set-up of the monitoring equipment is sometimes a hurdle.

Activated protein C is the only drug with FDA approval specifically for treatment of sepsis. Prospective observational studies demonstrated an absolute decrease in the level of activated protein C in some patients with severe sepsis and a subsequent increase in mortality. However, there is much debate as to its efficacy. 

What is standard practice in your hospital?  Are you using rH-APC — why or why not?

Keep in mind: APC is only FDA approved for patients with an APACHE score greater than 25.  An online APACHE calculator is available at www.mdcalc.com/apacheii.

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