Tet Spell Treatment Mnemonic?

[RustedFox]

Hey all,

I may be hallucinating, but I seem to remember some sort of mnemonic somewhere along the line that outlined the treatment of a tet spell (Note: NOT the anatomic features of the tetralogy itself, but rather the acute interventions). Anyone got one ?

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[RustedFox]

.... or if anyone wants to get creative and make one up... I'm all ears.

#selfconfessedmnemonicjunkie

 

[Apollyon]

First time you learn about Tetralogy of Fallot is in embryo as a first year.

Next time you learn about it is either on peds or on CT surgery, treating it, alleviating the tet spells.

As such, I, for one, who is a trivia master, do not know this mnemonic (or "pneumonic", as to which has been attested on SDN). For 2, I don't know that it is still relevant in the first world. Third, you gave it 1 hour, from 11pm to midnight EST.

I thought that it was only for the kid to squat down, and that, as they are "spells", it may resolve on its own. I shall be first to admit that, were a child to present having a tet spell, I would not recall the treatment, and would put on oxygen, and consult the internet.

 

[pinipig523]

Tet spell means you need to increase SVR in order to promote blood into the overriding PA.

I thought that was all there was to it. And then cards f/up.

 

[EM_Rebuilder]

I vaguely remember knee to chest and Morphine.

As above, google would be my friend...

 

[had2piknowEM]

I thought knee to chest and Phenylephrine...but never remembered a mnemonic

 

[cyclohexanol]

I thought knee to chest and Phenylephrine...but never remembered a mnemonic

Correct. Phenylepherine 0.02mg/kg --> increased SVR --> decreased L->R shunt

I can't recall any mnemonic either.

 

[RustedFox]

First time you learn about Tetralogy of Fallot is in embryo as a first year.

Next time you learn about it is either on peds or on CT surgery, treating it, alleviating the tet spells.

As such, I, for one, who is a trivia master, do not know this mnemonic (or "pneumonic", as to which has been attested on SDN). For 2, I don't know that it is still relevant in the first world. Third, you gave it 1 hour, from 11pm to midnight EST.

I thought that it was only for the kid to squat down, and that, as they are "spells", it may resolve on its own. I shall be first to admit that, were a child to present having a tet spell, I would not recall the treatment, and would put on oxygen, and consult the internet.

Jeez, man. - "I gave it an hour"... I just wanted to update my post before I hit the sack, giving everyone the invitation to get creative. Sure, I can look up the treatment and make my own, but for some odd reason, I seem to remember some peds EM folks on here having a rather clever one.

 

[Apollyon]

Jeez, man. - "I gave it an hour"... I just wanted to update my post before I hit the sack, giving everyone the invitation to get creative. Sure, I can look up the treatment and make my own, but for some odd reason, I seem to remember some peds EM folks on here having a rather clever one.

It looked like a bump to me.

Even so, how creative can a mnemonic be for "knee to chest" and "phenylephrine"? The mnemonic would be as long as the actual treatment.

 

[RustedFox]

It was a short one if I remember correctly, but it included knee-to-chest, O2, morphine, phenylephrine... one or two little other nuances. The reason I'm so after it is because it was so damn clever... related to "tet spell" in some undeniable way. I'm putting together a "pediEM handbook for residents", and I really wanted that'n to be in there.

 

[WilcoWorld]

Here's one I'm making up right now.

Because congenital heart disease makes EM docs poop their pants:
My Poor Khakis = Morphine, Phenylephrine, Knee-to-chest

 

[EM_Rebuilder]

Here's one I'm making up right now.

Because congenital heart disease makes EM docs poop their pants:
My Poor Khakis = Morphine, Phenylephrine, Knee-to-chest

How about Keep Me Pumping?

Thats in a better order of use and has something to do with the topic?

 

[Hamhock]

My knowledge of pediatric cardiology is pretty limited and if I ever end up with a "tet spell" in front of me, I guess I will just resort to the knees-to-chest and oxygen and then consider phenylephrine and morphine.

I wonder, however, if the morphine is just used to increase the pulmonary vascular capacity/decrease pulm pressures further below systemic pressures. If so, I wonder if nitro wouldn't be a better choice; just like sympathetic surge/acute "CHF" management in adults.

Any pedi folks out there want to chip in?

I wonder if my morphine reflex is just like the old-school reflex for lasix and morphine for sympathetic surge "CHF" in adults.

HH

 

[J-Rad]

Is a Tet spell (hypercyanotic episode) a first world problem? Yes*. The most likely scenario is going to be the kid who was born with Tet diagnosed pre- or post-natally who had acceptable O2 sats (especially after the ductus was closed or mostly closed) and wasn't having spells in the Newborn Nursery/NICU. They were sent home with close follow up for plans for later full intracardiac repair (not to stray too far afield, but there are other defects that may be sent home pending either full repair or a palliative procedure that may be a set up for a hypercyanotic episode. They will have some defect that includes pulmonary stenosis especially at the muscular, sub-valve level**) The parents will have been counseled as to the recognition (often occurs after prolonged crying, defecation, or eating and they may have a sudden decrease in level of consciousness and increase in cyanosis) and home management (calm baby, knee-to-chest, and O2 if they have it) of a spell. If the baby has made it to the ED it's probably because they are not improving. If that isn't the case and they have improved and you're documenting sats that are at baseline then you can continue with BBO2 and keeping baby with Mom/Dad to keep her calm until you've spoken to the baby's cardiologist/cardiology group.

If the baby is not improving, the goal of treatment for a Tet spell is to increase O2 supply to the tissue (decreased by some mechanism that led to increased right-to-left shunt. The truth is no one knows the exact pathophys. of a hypercyanotic episode. One long held theory is that there is dyanamic infundibular obstruction-this led to the use of BBs either for actute or prophylactic management) while decreasing O2 demand.

So the baby has not improved and has come to you with lousy sats, AMS, and acidosis. While someone is calling the cardiologist for their specific guidance continue O2. While morphine is good at calming a child and maybe reducing O2 demand, ketamine may be an even better drug given its calming effect and its known effect on SVR (increase). Phenylepherine is also a good drug to increase SVR. There is some thought that as babies approach their physiologic nadir of H&H they are more prone to Tet spells. In a child who is not improving PRBCs may be in order. Some advocate bicarb to treat acidosis. If you are throwing all this stuff at the kid and they are still not improving (hopefully by now there is a helicopter on the way if you aren't at or near the cardiac center) you are probably at the point that you need to consider controlling the airway. If you are in that pickle, don't use drugs that are going to acutely drop the SVR. Your consulting cardiologist may or may not recommend beta blockers as part of the acute management of the spell depending on their opinion of their use in that setting. If you're at or near the cardiac center, hopefully the kid got out of your ED before there was any talk of tubing the kid and they're already on their way to the peds cath lab for a balloon dilation of the RVOT or to the OR for an urgent systemic to pulmonary artery shunt (depending on center preference).

Sorry, I don't have a good mnemonic for this though

*In the first world, it would be much less likely to see the toddler who runs around and does the classic squatting to treat their own spell. Assuming regular healthcare, their murmur would likely have been caught and they would have been diagnosed and repaired in infancy.

**Double outlet right ventricle with sub-pulmonary stenosis awaiting full repair, Double inlet left ventricle or tricuspid atresia with normally related great vessels and PS who may have been balanced enough to postentially get away without a stage I palliation and are awaiting a Glenn shunt. Just some examples.

 

[Apollyon]

Is a Tet spell (hypercyanotic episode) a first world problem? Yes*.

Perhaps I am being a bit on the sensitive side, but, considering your word choice, I detect some snark from this line (consider the animus you've had towards me). Is it a first-world problem? As peds cards, you see it, so "yes". However, what are the numbers for known tetralogies that are discharged home before repair? That is the question of relevance. Is it on the lines of the 10 or so cases in the US per year (out of more than 114 million visits) for Y. pestis plague (in Arizona and New Mexico), or the 50 cases of malaria, including autochthonous cases in NYC, or 1000 (3 a day across the US), or 10K, or 50 thousand? (Although, to be honest, I know 50K is exaggerating).

The incidence of 3-6 per 10000 gives 1200-2400/year (based on 4million births per year). Cut it in the middle, and that is 1800. How many of those 1800 are discharged home before surgery in the US (as a surrogate for the first world)?

And another reference said 2/10000 - that would be 800 cases per year. Surgery by 1 year of age, mostly by 6 months - what percent are in the hospital for their entire first 6 months of life? And how do you get a 3 month old to squat, or does knee-chest work if you move them, instead of the patient? Your marked note states that is "much less likely" to see the toddler. That is, again, the relevance about which I ask.

(All of my post is since and professional, with no ulterior motive or subtext.)

 

[J-Rad]

Perhaps I am being a bit on the sensitive side, but, considering your word choice, I detect some snark from this line (consider the animus you've had towards me).

[YOUTUBE]http://www.youtube.com/watch?v=ip4pXmVpek0[/YOUTUBE]
Friend, there is and never was animus. "There is no us". No snark and if you go to the footer you'll see that I agreed that there has been a shift in epidemiolgy that make some presentations of tet not a first world problem. It was a legitimate question that I tried to give a legitimate answer to it. Yes, you're being overly sensitive.


Is it a first-world problem? As peds cards, you see it, so "yes". However, what are the numbers for known tetralogies that are discharged home before repair? That is the question of relevance. Is it on the lines of the 10 or so cases in the US per year (out of more than 114 million visits) for Y. pestis plague (in Arizona and New Mexico), or the 50 cases of malaria, including autochthonous cases in NYC, or 1000 (3 a day across the US), or 10K, or 50 thousand? (Although, to be honest, I know 50K is exaggerating).

The incidence of 3-6 per 10000 gives 1200-2400/year (based on 4million births per year). Cut it in the middle, and that is 1800. How many of those 1800 are discharged home before surgery in the US (as a surrogate for the first world)?

And another reference said 2/10000 - that would be 800 cases per year. Surgery by 1 year of age, mostly by 6 months - what percent are in the hospital for their entire first 6 months of life? And how do you get a 3 month old to squat, or does knee-chest work if you move them, instead of the patient? Your marked note states that is "much less likely" to see the toddler. That is, again, the relevance about which I ask.

(All of my post is since and professional, with no ulterior motive or subtext.)

I don't know the exact numbers of how many Tets get sent home from the nursery without a palliative shunt awaiting repair. My feeling is that quite a few do. Very few spend their first six months of life in the hospital. OP thought a Tet spell was something he should know how to treat; I tried to help.


As for going through numbers and percentages, you could go down this line of thought: while congenital heart disease is the most common birth defect it still accounts for less than 1% of the population. Is there really any reason for the ED doc to be able to recognize and treat suspected critical CHD given the low numbers. Does critical CHD ever show up in the ED? And before you continue to think that this is an extension of some imagined snark, this is a question that can be posed for many severe diseases of childhood that are uncommon, but potentially devastating. It is also why I value the well trained emergency doc over the poorly trained doc/NP/PA-in-the-box at the local UCC.

 

[Apollyon]

What I was going to say, but forgot, is that they still taught us (or me, at least - I finished residency 2006) about BAL for arsenic poisoning, among many other poisons that were "one toxin, one antidote". There is a lot of EM that is low-yield.

My month in the PICU taught me, honestly, few things. One was that the normal sat was either 98-100% or 85% (if you had an inkling it was something hypoxic, go with the 85).

As you said, as I said, put oxygen on them. I am not blowing it off because of the unlikelihood of seeing it. However, if a parent says that that the child had a Norwood or Blalock-Taussig (which I believe has been supplanted) or a Glenn or this bypass or that baffle, I am going to have to look it up, and probably still won't understand the diagrams.

And, completely honestly, if a mother comes in, in active labor, with no prenatal care, and has a baby with complete transposition of the great vessels, I am not going to know that this is the infant that is dead from the first breath, but only that the APGAR will be 3 or 4 at 1 minute, and zero at 5 minutes. And, then, I shall be (figuratively, if not literally) crapping my pants.

 

[WilcoWorld]

How about Keep Me Pumping?

Thats in a better order of use and has something to do with the topic?

It's also better because I don't wear Khakis...

 

[pinipig523]

I just came across this question when reviewing Peer 8, phenylephrine 0.01mg/kg for Tet spells. Everyone above me is right about pheny.

I thought of this thread when I saw it.

 

[J-Rad]

BTW, I should have mentioned that, except in cases as rare as hens' teeth (rendering the situation virtually irrelevant to the discussion), Tets don't go into heart failure. A legitimate part of your treatment algorithm are fluid boluses in your attempts to increase SVR.