Pediatric dysrhythmias Treatment not required Treatment is required Sinus arrhythmia Supraventricular tachycardia Wandering atrial pacemaker Isolated premature atrial contractions Isolated premature Ventricular tachycardia ventricular contractions First degree AV block Third degree AV block with symptomsReproduced from Zitelli’s Atlas of Pediatric physical diagnosis, 2007, pg 140.
Pediatric dysrhythmias Vital to be aware of arrhythmias that occur in otherwise healthy children Management is individualized Does child have history of heart disease? Are symptoms present?
Sinus arrhythmia Most common irregularity of heart rhythm seen in children Normal variant Reflects healthy interaction between autonomic respiratory and cardiac control activity in CNS Heart rate increases during inspiration and decreases during respiration
First degree AV block Commonly seen (up to 6% normal neonates) PR interval is greater than upper limits of normal for a given age PR interval is age and rate dependent 70-170 msec in newborns is normal 80-220 msec in young children and adults Generally does not cause bradycardia since AV conduction remains intact
First degree AV block Diseases that can be associated with first degree AV block: rheumatic fever, rubella, mumps, hypothermia, cardiomyopathy, electrolyte disturbances
Third degree AV block AKA complete heart block Most common cause of abnormal bradycardia in infants and children Complete disassociation between P waves and QRS complexes
Third degree AV block Can be congenital – in this case it is strongly associated with maternal SLE Mom of an infant should be worked up Most common structural heart defect associated is corrected transposition of great vessels
Third degree AV block May be asymptomatic – follow clinically Slower the heart rate, and wide QRS escape rhythms place into high risk group May need implantable pacemaker: significant bradycardias, syncope, exercise intolerance, ventricular dysrhythmias, or ventricular arrhythmias, structural disease Possible acute treatment: isoproterenol
Supraventricular tachycardia Most common abnormal tachycardia seen in pediatric practice Most common arrhythmia requiring treatment in pediatric population Most frequent age presentation: 1 st 3 months of life, 2nd peaks @ 8-10 and in adolescense Rapid, regular, usually narrow QRS rhythm, originating above the ventricles
SVTFigure 5-42 Supraventricular tachycardia. Note a normal QRS complextachycardia at a rate of 214 beats/minute without visible P waves.
SVT Paroxysmal, sudden onset & offset Rates of SVT vary with age Overall average rate for all ages: 235 bpm – 1st 9 months of life: avg rate is 270 bpm – Older children: avg rate is 210 bpm( 180-250) P waves difficult to define, but 1:1 with QRS Important to differentiate from sinus tach
SVT Older kids can describe a sensation of a fast heart rate, palpitations, or chest tightness Hemodynamic compromise in newborns and those with structural heart disease Those with typical symptoms would benefit from cardiac consultation
SVT - Treatment Goal: identify unstable patients, differentiate from sinus tachycardia, and terminate the rhythm Vagal maneuvers in stable patients(successful in 80%) – Carotid sinus massage – Ice pack on face Adenosine if IV access readily available(Rx of choice) – Stop conduction through AV node – Helps to define p waves if unsure of etiology – 0.1 mg/kg (max 6 mg), repeat 0.2 mg/kg ( max 12 mg) in line closest to central circulation – Need continuous ECG and BP monitoring Synchronized cardioversion Amiodarone, Procainamide if above unsuccessful Transesophageal atrial pacing can also be performed
SVT - Treatment Need post conversion ECG – identify those with WPW syndrome ( 25 % pts with SVT) Will also need an echo – identify structural problems Radiofrequency catheter ablation – Frontline treatment – Very effective – Cutoff points usually are 5 y.o. and 15 kg, unless severe SVT Observation and expectant management Medications – Digoxin and beta blockers as first line – Flecainide, sotalol, amiodarone
SVT - WPWFigure 5-43 Wolff-Parkinson-White syndrome. Note the characteristic findings of a short P-Rinterval, slurred upstroke of QRS (delta wave), and prolongation of the QRS interval.
Ventricular tachycardia Sustained V-tach is uncommon, needs workup Regular wide complex tachycardia Atrioventricular dissociation Life threatening arryhthmia Often presents in those who have had open heart surgical repair, or those with cardiomyopathies, myocarditis, or tumors
V-Tach Treatment: IV lidocaine, procainamide, amiodarone If critically ill: synchronized cardioversion Long term: meds, ablation, or defibrillator
Ventricular fibrillation Seen in children with EKG abnormalities such as long QT syndrome, or Brugada syndrome Cardiomyopathies, structural heart disease causing ventricular dysfunction Treatment: immediate defibrillation, CPR
Sinus tachycardia can be associated with : a) Fever b) Hemorrhage c) Exercise d) Breath holding e) Anxiety f)anaemia
A 6-week-old infant is brought to the well-baby visit. nurse discovers a rapid heart rate. The ECG shows a regular, narrow QRS tachycardia with a rate of 260 beats/minute. Appropriate therapy for this problem could include all of the following a) Intravenous administration of adenosine b) Placing an examination glove filled with ice over the infants forehead c) Intravenous administration of verapamil d) Application of gentle abdominal pressure to mimic a Valsalva maneuver e)Cardioversion
T/F concerning congenital complete heart bock a) It can be associated with maternal systemic lupus erythematosus. b) It can be associated with complex congenital heart disease. c) It is typically treated with a cardiac pacemaker. d) The ECG typically demonstrates a prolonged PR interval. E)associated with TGA
Causes for syncope in children are? a) Severe aortic stenosis b) Long QT syndrome c) Seizure disorder d) Fluid depletion e) Hypoglycemia f)Breath-holding spells g) Hypertrophic cardiomyopathy h) Neurocardiogenic syncope