The words ‘persistent tachycardia’ will strike a chill in many of you reading, but there will be those wondering what all the fuss is about. This article is aimed at that latter group in the hope that you can learn the lessons of both the past and present to recognise and treat a deteriorating child.
The observation charts below show the pulse rates of an imaginary two-year-old admitted and on ceftriaxone 80mg/kg in Australia and the UK, using the New South Wales (NSW) current ‘Between the Flags’ (BTF) observation chart and a generic UK based chart.
The most striking feature is that the pulse rate is above the ‘accepted’ level for a number of hours and is what myself and many others would define as ‘persistent tachycardia’ (PT) –
’I’ll huff and I’ll puff…’
However, like many things in medicine, you will not necessarily find this written in any textbooks or scholarly articles and no specific definition currently exists. When does it become persistent? 2hrs? 4hrs? Personally, using the charts above, it would be at 1300-1400hrs but this is an evidence void.
So, what’s it all about and why does it matter? Well, this article isn’t about cardiovascular physiology or the mechanism of sepsis. My hope is to make you think, really think, about what might be going on.
’I’ll blow your house down’
Whether a child with persistent tachycardia is on antibiotics or not, escalation is required in terms of:
- Senior decision making and review – Yes, wake your Consultant up whatever the hour to make them aware and discuss.
- Bloods – do another gas, where is the lactate heading?
- Antibiotic choice – Do you need to cover gram -ve (gentamicin chaser) or toxic shock syndrome (clindamycin)?
- Further fluid boluses – 10ml/kg vs 20ml/kg dependant on your practice…
There will be a plethora of cases in many readers experiences where the predominant feature of a septic child has been persistent tachycardia. Some will have been acted on, whilst others may have been missed or accepted as ’they’re just sick’ with potentially devastating consequences. The Clinical Excellence Commission (CEC), NSW published a document in 2017 highlighting seven root cause analysis investigations (read – significant morbidity or mortality) across the state where the common theme was persistent tachycardia. The Royal Children’s Hospital, Melbourne highlights the importance of persistent tachycardia in their current ’febrile child’ guideline along as does Queensland.
But what about the UK? The National Institute for Health and Care Excellence (NICE) has a multitude of guidelines covering sepsis and fever in children but at the time of writing persistent tachycardia is not mentioned. Many junior and senior trainees I interact with are new to the concept of persistent tachycardia and this is probably not isolated to a little hospital in Surrey, UK.
‘But a paediatric early warning system (PEWS), BTF or the NHS-SPOT (System-wide Paediatric Observations Tracking) programme will pick these children up?’ I hear you say…
Well, yes and no. A PEWS system or variant thereof, which nearly all hospitals now use, should cause an escalation in treatment and/or care. However, this ignores human factors and the complexity of systems within medicine as noted by Cheung, Roland and Lachman (2018). Many readers will have experienced this blindness or ‘learnt acceptance’ to ignore abnormal observations/PEWS score on a patient with, in some instances, devastating outcomes.
Persistent tachycardia is a phrase I hope becomes part of your own healthcare culture and practice. It’s one part of a safety culture that should include a PEWS based system.
Don’t be afraid of the big bad wolf but don’t ignore it either…
What do you think? Can we discharge children with persistent tachycardia? Let us know in the comments below