🧸 Pediatrics · Lesson 3 of 5 · 7 min
Tet Spells, Coarctation and the Strawberry Tongue
💙 A blue infant pulls his knees to his chest and the color improves. He is not being cute. He is treating his own heart defect, and the exam wants you to help him do it.
💡 Key idea
Tet spell: knee-chest, oxygen, calm, morphine. Coarctation: arms higher than legs. Kawasaki: 5 days of fever, strawberry tongue, peeling hands; IVIG and aspirin, watch the coronaries.
🧠 Why it matters
TETRALOGY OF FALLOT (pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy) causes cyanosis; during a hypercyanotic TET SPELL, place the infant in the KNEE-CHEST position (older children squat), give oxygen, calm the child, and give morphine as ordered to reduce the spell. Squatting increases systemic resistance and pushes blood through the lungs. COARCTATION OF THE AORTA: blood pressure and pulses are HIGHER in the arms than the legs, with weak or absent femoral pulses; check four-extremity blood pressures. ACYANOTIC defects with left-to-right shunts (ventricular and atrial septal defects, patent ductus arteriosus) cause heart failure signs: poor feeding, sweating with feeds, failure to thrive and tachypnea; feed small amounts frequently with a soft nipple and give digoxin and diuretics as ordered. KAWASAKI DISEASE: fever for 5 or more days plus conjunctival redness without discharge, a STRAWBERRY TONGUE and cracked red lips, a rash, swollen hands and feet with later PEELING, and swollen cervical nodes; treated with IV immune globulin and aspirin (one of the few pediatric uses of aspirin), with echocardiograms to watch for coronary artery aneurysms; live vaccines are delayed for 11 months after IVIG. RHEUMATIC FEVER follows untreated group A strep infections: joint pain, carditis, chorea and a rash; prevention is finishing the full course of antibiotics for strep throat.
🏥 In the real world
🫀 A 4-year-old with tetralogy of Fallot becomes dusky and breathless while crying over a blood draw. He drops into a squat on the floor. The nurse does not pull him up; she stays with him, applies oxygen and lets the squat do its work while she calls for morphine. Within minutes his color returns. The child's instinct was the textbook intervention.
📌 Takeaways
- Tet spells: knee-chest or squatting, oxygen, calm, morphine
- Coarctation: upper extremity pressure higher than lower, weak femoral pulses
- Kawasaki: IVIG and aspirin; coronary aneurysms are the danger
📖 Terms in this lesson
Tet spell: A sudden cyanotic episode in tetralogy of Fallot, relieved by the knee-chest position and oxygen.
Kawasaki disease: A childhood illness with five days of fever, a strawberry tongue and peeling hands, treated with IVIG and aspirin to protect the coronary arteries.
PROVe (tetralogy of Fallot): Pulmonary stenosis, Right ventricular hypertrophy, Overriding aorta, Ventricular septal defect: the four defects of tetralogy of Fallot, the cyanotic heart defect behind tet spells.
✅ Test yourself
An infant with tetralogy of Fallot becomes acutely cyanotic and irritable. Which action should the nurse take first?
- Place the infant supine with legs extended
- Prepare for immediate surgery
- Offer a bottle of formula to calm the infant
- Place the infant in a knee-chest position
Answer: D · Place the infant in a knee-chest position
The knee-chest position increases systemic vascular resistance, directing more blood to the lungs and relieving the spell; oxygen is given at the same time.
Which assessment finding suggests coarctation of the aorta in an infant?
- Bounding femoral pulses
- Weak or absent femoral pulses
- Cyanosis that improves with crying
- Equal four-extremity blood pressures
Answer: B · Weak or absent femoral pulses
The narrowing distal to the arm vessels raises upper-body pressure and weakens lower-body pulses, so blood pressure is higher in the arms than the legs.
A child has had a fever for 6 days, red cracked lips, a strawberry tongue and swollen hands. Which treatment does the nurse anticipate?
- Corticosteroids and bed rest
- Antiviral medication
- IV immune globulin and aspirin
- Antibiotics only
Answer: C · IV immune globulin and aspirin
These are the criteria for Kawasaki disease; IVIG and aspirin reduce the risk of coronary artery aneurysms.
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