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Evaluation & Management Of Child With Arrhythmias
 

Evaluation & Management Of Child With Arrhythmias

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The management of a child in case of Bradycardia, Tachycardia, Irregular Rhythm, and V-tech. The all the details and treatment is shown in form of alogrithm and ECG's.

The management of a child in case of Bradycardia, Tachycardia, Irregular Rhythm, and V-tech. The all the details and treatment is shown in form of alogrithm and ECG's.

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  • Associated with myocarditis,anomalous origin of coron. A. rt.vent.dysplasia, mitral valve prolapse, CMP, LQTS, WPW synd. Drugs(cocaine, amphetamine)

Evaluation & Management Of Child With Arrhythmias Evaluation & Management Of Child With Arrhythmias Presentation Transcript

  • Evaluation & Management of a Child with Arrhythmias
    By
    Dr.SaimaBashir
    Post Graduate Trainee
    Pediatric medicine unit-I
    Mayo Hospital Lahore
  • Definition
    Cardiac arrhythmia (also dysrhythmia) is a term for any of a large and heterogeneous group of conditions in which there is abnormal electrical activity in the heart. The heart beat may be too fast or too slow, and may be regular or irregular.
  • Classification Of Arrhythmias
    Tachycardia
    Bradycardia
    Sinus tachycardia
    SVT
    Vent. Fib
    Vent. Tachy
    Atril fib.
    Atrial flutter
    Sinus bradycardia
    Heart block
    Irregular
    Sinus arrhythmia
    PAC
    PVC
  • Causes Of Arrhythmias
    Congenital
    Acquired
    In structurally normal/ abnormal heart
    Congenital metabolic disorders of mitochondria
    SLE
    Rheumatic fever
    Myocarditis
    Toxin (diphtheria)
    Pro-arrhythmic or anti-arrhythmic drugs
    Surgical correction of CHD
  • Why Basic Understandning Of Arrhytmias Is Important???
    Major risk of an arrhythmia is either severe bradycardia or tachycadiadec. cardiac output
    degeneration into more severe arrhythmias (vent. fib.)
    To be aware of arrhythmias that occur in otherwise healthy children
  • Symptoms
    Range from
    Completely asymptomatic
    Loss of consciousness
    Sudden cardiac death
    In infants
    Lethargy
    Poor feeding
    Irritability
    Cardiac failure
    Underlying congenital
    heart disease
    In children
    Palpitation
    Syncope
    Dizziness
    Chronic fatigue
    Shortness of breath
    Chest discomfort
  • Examination
    GPE
    Pulse__ irregular, feeble, inc./dec. rate, absent
    Tachypnea
    B.P __ Normal, hypotension
    JVP __ raised in CCF
    Cyanosis
    Pallor
    CVS
    Precordial bulge
    Right ventricular heave
    Gallop
    Murmur
  • Respiratory system
    Bil. Crepts (pulm. edema)
    GIT
    Hepatomegaly
    CNS
    Normal
    Hpotonia
  • Evaluation Of The Child With An Arrhythmia
    History
    Symptoms
    Frequency and length of episode
    Onset and triggers
    Any underlying disease
    Medications
    Triggering factor
    Used for underlying cardiac disease
  • Evaluation Of The Child With An Arrhythmia
    Physical examination
    ABC’s
    Hemodynamic stability
    Adjunctive testing
    12-Lead ECG
    Holter
    External event recorders
    Exercise testing
  • Evaluation Of The Child With An Arrhythmia
    Patient with arrhythmia
    Ensure ABCs
    Absent
    Asystole
    Assess rhythm
    V FIB
    Pulseless V Tach
    PEA
    Absent
    Assess pulse
    Present
    Irregular
    Fast
    Slow
    Narrow QRS
    Wide QRS
    Sinus Bradycardia
    AVN Block
    Sick Sinus
    Sinus arrhythmia
    Atrial FIB
    PAC +/- Block
    PVC
    Sinus Tachycardia
    SVT (PAT)
    Atrial flutter
    V TACH
    V FIB
  • Evaluation Of The Child With An Arrhythmia
    Assess Pulse
    Irregular
    Fast
    Slow
    P- Wave
    PR-Interval
    Prolonged PR-Interval
    Normal
    Heart- block
    Sinus Bradycardia
  • Evaluation Of The Child With An Arrhythmia
    Assess Pulse
    Irregular
    Fast
    Slow
    P- Wave
    QRS- Complex
    • Fibrillatory (Multiple P- Wave )
    • Normal QRS- Complex
    Normal
    • Normal but different shape QRS complex
    • P- Wave Present
    Wide QRS- complex
    Sinus Arrythmia
    PVC
    PAC
    Atrial Fib.
  • Evaluation Of The Child With An Arrhythmia
    Assess Pulse
    Irregular
    Fast
    Slow
    QRS- Complex
    QS Wide
    QRS Normal
    P- Wave
    P- Wave
    Absent or Atriovent dissociation
    Present
    Absent
    Sawtooth
    Appearance
    • No P- Wave
    • low amplitude QRS- Complex
    Sinus trachycardia
    SVT
    Atrial flutter
    V- Tech
    V- Fib.
  • Pediatric Dysrhythmias
    Reproduced from Zitelli’s Atlas of Pediatric physical diagnosis, 2007, pg 140.
  • Sinus Rhythm
    Every QRS complex is preceded by a P wave and every P wave must be followed by a QRS (the opposite occurs if there is second or third degree AV block).
    The P wave morphology and axis must be normal and
    PR interval will usually be normal for that age
  • 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 expiration
  • Sinus Arrhythmia
    Normal phasic variation of heart rate with respiration
    Variable P-P intervals
    No treatment needed
  • Wandering Atrial Pacemaker
    normal QRS complex
    Change in P-wave configuration
  • Atrial pacemaker shifts intermittently from sinus node to another atrial site
    Normal variant
    May also be seen in CNS disturbances like subarachnoid hemorrhage
    Wandering Atrial Pacemaker
  • Premature Atrial Contraction
    Ectopic focus in atria or AV node
    Narrow but normal QRS
    Normal P wave
  • Isolated PAC’s
    Premature atrial contractions
    Benign in absence of underlying heart disease
    Common in newborn period
    Early p wave, sometimes with different morphology than a sinus p wave
    Can be either:
    Not conducted to ventricle, apparent pause
    Conducted to ventricle with aberrant or widened QRS complex ( careful not to mix up with PVC’s)
  • Premature Ventricular Contraction
    Ectopic beat activates ventricle before the wave of depolarization from normal sinus node
    Abnormally wide QRS complex appears early which are not preceded by P-wave
    T-wave points in the direction opposite to QRS complex
    Bigeminy, trigeminy, couplet
    Unifocal, multifocal
    Three or more successive PVCs are termed as ventricular tachycardia
  • Premature Ventricular Contraction
    Not very commonly seen in children
    Incidence of 0.3 to 2.2 %
    Myocarditis
    cardiomyopathy
    CHD
    hypokalemia
    Hypoxia
    Drugs:Digitalis toxicity, catecholamines, theophylline, caffeine, anesthetics, Class I and III anti-arrhythmics
    myocardial injury
    long QT syndrome
    hypomagnesemia
  • unifocal,
    disappear with exercise, and
    associated with structurally and functionally normal heart, then considered benign, no therapy needed
    PVC’s
  • PVC’s Evaluation
    Indicated if
    Two or more PVCs in a row
    Multifocal origin
    Increased vent. Ectopic activity with exercise
    R on T phenomenon (PVC occurs on preceding beat)
    Presence of underlying heart disease
  • PVC’s Evaluation
    12 lead EKG, Echocardiogram
    Perhaps Holter monitoring
    Brief exercise in office to see if ectopy suppressed or more frequent
    Treatment:
    • Correction of underlying condition
    • IV lignocaine – 1st line drug
    • Amiodarone in refractory cases with hemodyanamic compromise
  • Evaluation Of The Child With An Arrhythmia
    Assess Pulse
    Irregular
    Fast
    Slow
    P- Wave
    PR-Interval
    Prolonged PR-Interval
    Normal
    Heart- block
    Sinus Bradycardia
  • Sinus Bradycardia
    Normal P wave axis and P-R interval
    HR < 5th percentile for age
  • Sinus Bradycardia
    Athletic individuals (normal)
    Increased ICP
    hyperkalemia
    vagal stimulation
    hypothermia
    Drugs: digoxin, beta-blockers, clonidine, opiods, sedative-hypnotics, amiodarone
    Treatment: address underlying cause
    hypoxia
    hypercalcemia
    hypothyroidism
    long QT syndrome
  • Long Q-T Syndrome
    Bradycardia
    Prolonged QT interva
    Notched T- wave
  • Long Q-T Syndrome
    Genetic abnormality of vent. Repolarization
    50% cases familial
    Romano Ward syndrome – common form of LQTS
    Drugs causing LQTS: terfenadine, cisapride, droperidol
    Clinical manifestation:
    Syncope induced by exercise, fright, startle
    Some events occur during sleep
    Seizures
    Palpitation
    Cardiac arrest (10%)
  • Long Q-T Syndrome
    Diagnostic criteria:
    QTc >0.47 __ indicative
    QTc >0.44 __ suggestive
    Notched T- wave
    Low heart rate for age
    Syncope
    Family H/O LQTS or unexplained sudden death
    Investigation
    12 lead ECG
    Holter Monitoring
    Exercise testing
  • Long Q-T Syndrome
    Treatment:
    Beta blockers __ to blunt heart response to exercise
    Pacemaker if drug induces profound bradycardia
    Implanted cardiac defibrillators
    Continuous syncope
    No response to drug treatment
    Experienced cardiac arrest
  • Sick Sinus Syndrome
    Result of abnormality in sinus node or atrial conduction pathway or both
    Arrhythmias include sinus bradycardia, blocks, sinus arrest with junctional escape, paroxysmal atrialtachycadia.
    Most common after surgical correction of CHD
    Clinical manifestations depend on heart rate
    Asymptomatic
    Dizziness
    Syncope
    Treatment: pacemaker therapy in symptomatic patient
  • Alogrithm For Pediatric Bradycardia
    • Assess and supports ABC’s
    • Provide 100% oxygen
    • Attach monitor
    • Vascular Access
    Yes
    No
    Is bradycardia causing severe cardiorespiratoycompromist??
    Poor perfusion, hypotension, respiratory difficulty. Altered conciousness
    • Observe
    • Support ABCs
    • Consider tranfer or transport to ALS facility
    Perform chest compression
    If despite oxygenation and ventilation
    HR <60/min in infant or child and poor systemic perfusion
    During CPR
    Attempt / verify
    Endotracheal intubation and vascular access
    Check
    • Electrode position and contact
    • Paddle position and contact
    Give
    • Epinephrine every 3 to 5 min( consider high doses for for second and subsequent doses) epinephrine or dopamine infusion
    Identify and treat causes
    • Hypoxemia
    • Hypothermia
    • Heart block
    • Heart transplant
    • Toxins/poisons/drugs
    Epinephrine
    • lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
    • Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)
    • May repeat every 3-5 min. at same dose
    Atropine: 0.02mg/kg
    (min.dose 0.1mg)
    • May be repeated once
    Give atropine 1st for bradycardia due to suspected increase vagal tone or primary AV block
    Consider cardiac pacing
    If pulseless arrest develops see pediatrics pulseless arrest algorithm
  • Alogrithm For Pediatric Bradycardia
    • Assess and supports ABC’s
    • Provide 100% oxygen
    • Attach monitor
    • Vascular Access
    • Assess and supports ABC’s
    • Provide 100% oxygen
    • Attach monitor
    • Vascular Access
    Is bradycardia causing severe cardiorespiratoycompromist??
    (Poor perfusion, hypotension, respiratory difficulty. Altered conciousness )
    Yes
    No
    Is bradycardia causing severe cardiorespiratoycompromist??
    Poor perfusion, hypotension, respiratory difficulty. Altered conciousness
    Perform chest compression
    If despite oxygenation and ventilation
    HR <60/min in infant or child and poor systemic perfusion
    • Observe
    • Support ABCs
    • Consider tranfer or transport to ALS facility
    • Observe
    • Support ABCs
    • Consider tranfer or transport to ALS facility
    Perform chest compression
    If despite oxygenation and ventilation
    HR <60/min in infant or child and poor systemic perfusion
    During CPR
    Attempt / verify
    Endotracheal intubation and vascular access
    Check
    • Electrode position and contact
    • Paddle position and contact
    Give
    • Epinephrine every 3 to 5 min( consider high doses for for second and subsequent doses) epinephrine or dopamine infusion
    Identify and treat causes
    • Hypoxemia
    • Hypothermia
    • Heart block
    • Heart transplant
    • Toxins/poisons/drugs
    During CPR
    Attempt / verify
    Endotracheal intubation and vascular access
    Check
    • Electrode position and contact
    • Paddle position and contact
    Give
    • Epinephrine every 3 to 5 min( consider high doses for for second and subsequent doses) epinephrine or dopamine infusion
    Identify and treat causes
    • Hypoxemia
    • Hypothermia
    • Heart block
    • Heart transplant
    • Toxins/poisons/drugs
    Epinephrine
    • lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
    • Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)
    • May repeat every 3-5 min. at same dose
    Epinephrine
    • lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
    • Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)
    • May repeat every 3-5 min. at same dose
    Atropine: 0.02mg/kg
    (min.dose 0.1mg)
    • May be repeated once
    Atropine: 0.02mg/kg
    (min.dose 0.1mg)
    • May be repeated once
    Give atropine 1st for bradycardia due to suspected increase vagal tone or primary AV block
    Give atropine 1st for bradycardia due to suspected increase vagal tone or primary AV block
    Consider cardiac pacing
    Consider cardiac pacing
    If pulseless arrest develops see pediatrics pulseless arrest algorithm
    If pulseless arrest develops see pediatrics pulseless arrest algorithm
  • AV Nodal Block First- Degree Heart Block
    Delayed conduction through AV node
    Prolongation of PR interval
  • 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
  • AV Nodal Block First-Degree Heart Block
    Usually asymptomatic
    Diseases that can be associated with first degree AV block:
    • Acute rheumatic fever
    • Lyme disease,
    • CHD (ASD, Ebstein’s anomaly),
    • cardiomyopathy,
    • post-cardiac surgery,
    • normal children
    • Hypothermia
    • Electrolyte disturbances
  • AV Nodal Block First-Degree Heart Block
    Drugs: Digitalis toxicity
    Treatment: Address underlying cause
    Isolated finding- benign, no treatment and no follow up needed
  • Second-Degree Heart Block:Mobitz Type I - Wenckebach
    P
    Progressive lengthening of PR interval until a QRS is not conducted (ventricular contraction does not occur)
  • Second-Degree Heart Block:Mobitz Type I - Wenckebach
    Does not usually progress to complete heart block
    Diseases that can be associated
    • Myocarditis,
    • cardiomyopathy,
    • CHD,
    • cardiac surgery,
    • MI,
    • normal children at times of increased parasympathetic activity
    Drugs: digitalis toxicity, beta-blocker toxicity
    Treatment: address underlying cause
  • Second-Degree Heart Block:Mobitz Type Il
    Constant PR interval before a skipped ventricular conduction
  • Block below the AV node in the bundle of His
    Not found in normal children, usually those with structural disease or post-op
    May progress to complete heart block
    May require pacemaker
    Second-Degree Heart Block:Mobitz Type Il
  • Third-Degree Heart Block: Complete
    Complete dissociation of atrial and ventricular conduction
    P wave and PR interval normal
    Junctional pacemaker – narrow QRS
    Ventricular pacemaker – wide QRS
    Rate 30 – 50 beats/min
  • Third-Degree Heart Block: Complete
    Congenital: maternal lupus or CT disease, CHD (L-TGA or abnormal AV septum)
    Acquired: post-op, acute rheumatic fever, Lyme carditis, myocarditis, cardiomyopathy, MI
    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
  • Sinus Tachycardia
    Normal sinus rhythm
    HR >95th percentile for age
    Usually < 230 beats/min
  • Sinus Tachycardia
    Hypovolemia
    Anemia
    fever
    CHF
    Drugs: Beta-agonists, aminophylline, atropine
    Treatment: address underlying cause.
    shock
    Sepsis
    anxiety
  • Supraventricular Tachycardia
    > 230 beats/min
    Narrow QRS
    P waves not visible
  • Supraventricular tachycardia
    Most common abnormal tachycardia seen in pediatric practice
    Most common arrhythmia requiring treatment in pediatric population
    Most frequent age presentation:
    • 1st 3 months of life,
    • 2nd peaks @ 8-10 and in adolescense
    Causes:
    • Idiopathic
    • CHD (Ebstein’s anomaly, transposition)
  • SVT - Presentation
    Paroxysmal, sudden onset & offset
    Rates of SVT vary with age
    Overall average rate for all ages: 235 bpm
    P waves difficult to define, but 1:1 with QRS
    Important to differentiate from sinus tachycardia
  • SVT - Presentation
    Older kids can describe a sensation of a fast heart rate, palpitations, or chest tightness
    Hemodynamic compromise (CCF) in newborns and those with structural heart disease
  • SVT -Treatment
    Goal:
    • identify unstable patients,
    • differentiate from sinus tachycardia, and
    • terminate the rhythm
  • Alogrithm For Pediatric Tachycardia With Adequate Perfusion
    • Assess and supports ABC’s (assess signs of circulation and pulse)
    • Provide oxygen and ventilation as needed
    • Attach monitor
    • Evaluate 12 lead ECG if pratical
    ≤0.08 sec
    > 0.08 sec
    Probable ventricular tachycardia
    Evaluate Rhythm
    What is QRS Duration?
    Probable supraventicular tachycardia
    • History incompatible
    • P-wave absent/ abnormal
    • HR not variable with activity
    • Abrupt rate changes
    • Infant : rate usually >220 bpm
    • Children: rate usually >180 bpm
    Consider alternative Medication
    Lidocane 1mg/ kg IV bolus (wide complex only)
    Probable sinus tachycardia
    • History compatible
    • P-wave present/Normal
    • HR often varies with activity
    • Variable RR with constant PR
    • Infant : rate usually <220 bpm
    • Children: rate usually <180 bpm
    During evaluation
    • Provide oxygen and ventilation as needed
    • Conform continuous monitor
    • Medical control consultation
    • Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg
    Consider Vagal Maneuvers
    (no delay)
    Establish vascular access
    • Consider adenosine 0.1mg/ kg lV/ lO (maximum first dose of 6 mg)
    • May double and repeat dose once (maximum 2nd dose of 12 mg)
    • Techniques: use rapid bolus technique
    Identify and treat possible causes
    Hypoxemia tamponade
    Hypovolemia tension pneumothorax
    Hyperthemiaposion/ toxin / drugs
    Hyper-/ hypokalemiathromoembolism
    Any further out of hospital interventions require medical control
    Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg
  • Alogrithm For Pediatric Tachycardia With Adequate Perfusion
    Assess and supports ABC’s (assess signs of circulation and pulse)
    Provide oxygen and ventilation as needed
    Attach monitor
    Evaluate 12 lead ECG if pratical
    • Assess and supports ABC’s (assess signs of circulation and pulse)
    • Provide oxygen and ventilation as needed
    • Attach monitor
    • Evaluate 12 lead ECG if pratical
    ≤0.08 sec
    &gt; 0.08 sec
    Probable ventricular tachycardia
    Evaluate Rhythm
    Evaluate Rhythm
    What is QRS Duration?
    What is QRS Duration?
    Probable supraventicular tachycardia
    • History incompatible
    • P-wave absent/ abnormal
    • HR not variable with activity
    • Abrupt rate changes
    • Infant : rate usually >220 bpm
    • Children: rate usually >180 bpm
    Probable supraventicular tachycardia
    • History incompatible
    • P-wave absent/ abnormal
    • HR not variable with activity
    • Abrupt rate changes
    • Infant : rate usually >220 bpm
    • Children: rate usually >180 bpm
    Consider alternative Medication
    Lidocane 1mg/ kg IV bolus (wide complex only)
    Probable sinus tachycardia
    • History compatible
    • P-wave present/Normal
    • HR often varies with activity
    • Variable RR with constant PR
    • Infant : rate usually <220 bpm
    • Children: rate usually <180 bpm
    During evaluation
    Provide oxygen and ventilation as needed
    Conform continuous monitor
    Medical control consultation
    Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg
    During evaluation
    • Provide oxygen and ventilation as needed
    • Conform continuous monitor
    • Medical control consultation
    • Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg
    Consider Vagal Maneuvers
    (no delay)
    Consider Vagal Maneuvers
    (no delay)
    Establish vascular access
    Consider adenosine 0.1mg/ kg lV/ lO (maximum first dose of 6 mg)
    May double and repeat dose once (maximum 2nd dose of 12 mg)
    Techniques: use rapid bolus technique
    Identify and treat possible causes
    Hypoxemia Tamponade
    Hypovolemia Tension pneumothorax
    HyperthemiaPosion/ toxin / drugs
    Hyper-/ hypokalemiaThromoembolism
    Establish vascular access
    • Consider adenosine 0.1mg/ kg lV/ lO (maximum first dose of 6 mg)
    • May double and repeat dose once (maximum 2nd dose of 12 mg)
    • Techniques: use rapid bolus technique
    Identify and treat possible causes
    Hypoxemia Tamponade
    Hypovolemia Tension pneumothorax
    HyperthemiaPosion/ toxin / drugs
    Hyper-/ hypokalemiaThromoembolism
    Any further out of hospital interventions require medical control
    Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg
    Any further out of hospital interventions require medical control
    Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg
  • Alogrithm For Pediatric Tachycardia With Poor Perfusion
    Assess and supports ABC’s
    NO
    • Initial CPR
    • See pulselessalogrithm
    Pulse Present?
    YES
    QRS duration normal for age(app. &gt; 0.08 sec)
    • Provide oxygen or ventilation as needed
    • Attach monitor
    QRS duration normal for age(app. &lt; 0.08 sec)
    Evaluate the tachycardia
    • 12 lead ECG if practical
    • Evaluate QRS duration
    Evaluate the tachycardia
    Probable venticular Tachycardia
    • Immediate Cardioversion
    • 0.5 to 1.0 j/kg (consider sedation do not delay cardioversion)
    Probable supraventicular tachycardia
    • History incompatible
    • P-wave absent/ abnormal
    • HR not variable with activity
    • Abrupt rate changes
    • Infant : rate usually >220 bpm
    • Children: rate usually >180 bpm
    Probable sinus tachycardia
    • History compatible
    • P-wave present/Normal
    • HR often varies with activity
    • Variable RR with constant PR
    • Infant : rate usually <220 bpm
    • Children: rate usually <180 bpm
    Consider alternative Medication
    Lidocane 1mg/ kg IV bolus (wide complex only)
    Immediate cardioversion
    • Attempt cardioversion with 0.5 to 1.0j/kg (may increase to 2j/kg if initial dose is ineffective)
    • Use sedation if possible
    • Sedation must not delay cardioversion
    OR
    ImmediatielV/lO adenosine
    • Adenosine: use if lV access immediately available
    • Dose: Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg)
    • May double and repeat dose once (max 2nd dose of 12 mg)
    • Technique: use rapid bolus technique
    Consider Vagal Maneuvers
    (no delay)
    During evaluation
    • Provide oxygen and ventilation as needed
    • Conform continuous monitor
    • Medical control consultation
    • Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg
    Identify and treat possible causes
    Hypoxemia tamponade
    Hypovolemia tension pneumothorax
    Hyperthemiaposion/ toxin / drugs
    Hyper-/ hypokalemiathromoembolism
  • Alogrithm For Pediatric Tachycardia With Poor Perfusion
    Assess and supports ABC’s
    Assess and supports ABC’s
    NO
    • Initial CPR
    • See pulselessalogrithm
    Pulse Present?
    Pulse Present?
    YES
    QRS duration normal for age(app. &gt; 0.08 sec)
    • Provide oxygen or ventilation as needed
    • Attach monitor
    • Provide oxygen or ventilation as needed
    • Attach monitor
    QRS duration normal for age(app. &lt; 0.08 sec)
    Evaluate the tachycardia
    • 12 lead ECG if practical
    • Evaluate QRS duration
    • 12 lead ECG if practical
    • Evaluate QRS duration
    Evaluate the tachycardia
    Evaluate the tachycardia
    Probable venticular Tachycardia
    • Immediate Cardioversion
    • 0.5 to 1.0 j/kg (consider sedation do not delay cardioversion)
    Probable supraventicular tachycardia
    • History incompatible
    • P-wave absent/ abnormal
    • HR not variable with activity
    • Abrupt rate changes
    • Infant : rate usually >220 bpm
    • Children: rate usually >180 bpm
    Probable supraventicular tachycardia
    • History incompatible
    • P-wave absent/ abnormal
    • HR not variable with activity
    • Abrupt rate changes
    • Infant : rate usually >220 bpm
    • Children: rate usually >180 bpm
    Probable sinus tachycardia
    • History compatible
    • P-wave present/Normal
    • HR often varies with activity
    • Variable RR with constant PR
    • Infant : rate usually <220 bpm
    • Children: rate usually <180 bpm
    Consider alternative Medication
    Lidocane 1mg/ kg IV bolus (wide complex only)
    Immediate cardioversion
    • Attempt cardioversion with 0.5 to 1.0j/kg (may increase to 2j/kg if initial dose is ineffective)
    • Use sedation if possible
    • Sedation must not delay cardioversion
    OR
    ImmediatielV/lO adenosine
    • Adenosine: use if lV access immediately available
    • Dose: Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg)
    • May double and repeat dose once (max 2nd dose of 12 mg)
    • Technique: use rapid bolus technique
    Immediate cardioversion
    • Attempt cardioversion with 0.5 to 1.0j/kg (may increase to 2j/kg if initial dose is ineffective)
    • Use sedation if possible
    • Sedation must not delay cardioversion
    OR
    ImmediatielV/lO adenosine
    • Adenosine: use if lV access immediately available
    • Dose: Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg)
    • May double and repeat dose once (max 2nd dose of 12 mg)
    • Technique: use rapid bolus technique
    Consider Vagal Maneuvers
    (no delay)
    Consider Vagal Maneuvers
    (no delay)
    During evaluation
    • Provide oxygen and ventilation as needed
    • Conform continuous monitor
    • Medical control consultation
    • Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg
    Identify and treat possible causes
    Hypoxemia Tamponade
    Hypovolemia Tension pneumothorax
    HyperthemiaPosion/ toxin / drugs
    Hyper-/ hypokalemiaThromoembolism
    During evaluation
    • Provide oxygen and ventilation as needed
    • Conform continuous monitor
    • Medical control consultation
    • Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg
    Identify and treat possible causes
    Hypoxemia tamponade
    Hypovolemia tension pneumothorax
    Hyperthemiaposion/ toxin / drugs
    Hyper-/ hypokalemiathromoembolism
  • SVT -Treatment
    Need post conversion EKG – identify those with WPW syndrome ( 25 % pts with SVT)
    Will also need an echo – identify structural problems
    Medications (to prevent recurrance)
    • Digoxin and beta blockers as first line
    • Flecainide, sotalol, amiodarone
    Observation and expectant management
    Radiofrequency catheter ablation
    • Frontline treatment
    • Very effective
    • Cutoff points usually are 5 y.o. and 15 kg, unless severe SVT
  • Supraventricular TachycardiaWPW
    • Accessory pathway establishes cyclic pattern of signal reentry
    • Impulse arrives at ventricle rapidly without delay at the AV node
    • Independent of AV node
    • Most common cause of nonsinus tachycardia in children
  • Wolff-Parkinson-White Syndrome
    • Delta wave
    • slurred upstroke of QRS
    • Reflects pre-excitation
    • Short PR- interval
    • Wide QRS complex
  • Atrial Flutter
    Dilated Atria, intraatrial surgery
    Digitalis toxicity
    Post-Fontan procedure patients
    Atrial rate 250-350 beats/min
    Sawtooth (no discrete P waves)
    Normal QRS complex
  • Atrial Flutter
    Chronic atrial flutter:
    Inc. risk of thromboembolism and stroke
    Anticoagulation
    Radiofrequency ablation in CHD in older child
    Management
    Emergency:
    Vagal maneuver
    adenosine
    Synchronized cardioversion0.5-2 J/kg
    Overdrive pacing
    Long term:
    Digoxin+/- B- Blockers
    Ablation
  • Atrial Fibrillation
    Atrial rate 350-600 beats/min
    Atrial waves are totally irregular
    P wave vary in size and shape from beat to beat
    vent. response is irregularly irregular
    QRS complexes are usually normal
  • Atrial Fibrillation
    Much less common
    Chronically stretched atria
    Intra atrial surgery
    Left atrial enlargement due to mitral valve insufficiency
    WPW syndrome
    Thyrotoxicosis
    Pulm. Embolism
    Pericarditis
    familial
  • Atrial Fibrillation
    Treatment:
    Restore normal heart rate by digitalization (avoided in WPW syndrome)
    Restore normal rhythm by adding quinidine/procainamide/DC cardioversion
    Prevention of thromboembolic phenomenon and stoke by warfarin
  • Ventricular Tachycardia
    120-150 beats/min
    Wide QRS
    3 or more consecutive beats from the ventricle (PVCs)
    85% have abnormal cardiac anatomy
    Metabolic abnormalities
    Drugs/toxins: tricyclic antidepressants
  • V-Tach
    Associated with
    Myocarditis
    Anomalous origin of coron. A.
    Rt. Vent. Dysplasia
    Mitral valve prolapse
    CMP
    LQTS
    WPW synd.
    Drugs(cocaine, amphetamine)
  • V-Tach
    Treatment: IV lidocaine, procainamide, amiodarone
    If critically ill: synchronized cardioversion
    Long term: meds, ablation, or defibrillator
  • Alogrithm For Pediatric Tachycardia With Adequate Perfusion
    • Assess and supports ABC’s (assess signs of circulation and pulse)
    • Provide oxygen and ventilation as needed
    • Attach monitor
    • Evaluate 12 lead ECG if practical
    0.08 sec
    0.08 sec
    Probable ventricular tachycardia
    Evaluate Rhythm
    What is QRS Duration?
    Probable supraventicular tachycardia
    • History incompatible
    • P-wave absent/ abnormal
    • HR not variable with activity
    • Abrupt rate changes
    • Infant : rate usually >220 bpm
    • Children: rate usually >180 bpm
    Consider alternative Medication
    Lidocane 1mg/ kg IV bolus (wide complex only)
    Probable sinus tachycardia
    • History compatible
    • P-wave present/Normal
    • HR often varies with activity
    • Variable RR with constant PR
    • Infant : rate usually <220 bpm
    • Children: rate usually <180 bpm
    During evaluation
    • Provide oxygen and ventilation as needed
    • Conform continuous monitor
    • Medical control consultation
    • Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg
    Consider Vagal Maneuvers
    (no delay)
    Establish vascular access
    • Consider adenosine 0.1mg/ kg lV/ lO (maximum first dose of 6 mg)
    • May double and repeat dose once (maximum 2nd dose of 12 mg)
    • Techniques: use rapid bolus technique
    Identify and treat possible causes
    Hypoxemia tamponade
    Hypovolemia tension pneumothorax
    Hyperthemiaposion/ toxin / drugs
    Hyper-/ hypokalemiathromoembolism
    Any further out of hospital interventions require medical control
    Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg
  • Alogrithm For Pediatric Tachycardia With Adequate Perfusion
    Assess and supports ABC’s (assess signs of circulation and pulse)
    Provide oxygen and ventilation as needed
    Attach monitor
    Evaluate 12 lead ECG if pratical
    • Assess and supports ABC’s (assess signs of circulation and pulse)
    • Provide oxygen and ventilation as needed
    • Attach monitor
    • Evaluate 12 lead ECG if practical
    0.08 sec
    0.08 sec
    Probable ventricular tachycardia
    What is QRS Duration?
    Probable ventricular tachycardia
    Evaluate Rhythm
    What is QRS Duration?
    Probable supraventicular tachycardia
    • History incompatible
    • P-wave absent/ abnormal
    • HR not variable with activity
    • Abrupt rate changes
    • Infant : rate usually >220 bpm
    • Children: rate usually >180 bpm
    Consider alternative Medication
    Lidocane 1mg/ kg IV bolus (wide complex only)
    Lidocane 1mg/ kg IV bolus (wide complex only)
    Consider alternative Medication
    Probable sinus tachycardia
    • History compatible
    • P-wave present/Normal
    • HR often varies with activity
    • Variable RR with constant PR
    • Infant : rate usually <220 bpm
    • Children: rate usually <180 bpm
    During evaluation
    • Provide oxygen and ventilation as needed
    • Conform continuous monitor
    • Medical control consultation
    • Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg
    During evaluation
    • Provide oxygen and ventilation as needed
    • Conform continuous monitor
    • Medical control consultation
    • Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg
    Consider Vagal Maneuvers
    (no delay)
    Establish vascular access
    • Consider adenosine 0.1mg/ kg lV/ lO (maximum first dose of 6 mg)
    • May double and repeat dose once (maximum 2nd dose of 12 mg)
    • Techniques: use rapid bolus technique
    Identify and treat possible causes
    Hypoxemia Tamponade
    Hypovolemia Tension pneumothorax
    HyperthemiaPosion/ toxin / drugs
    Hyper-/ hypokalemiaThromoembolism
    Identify and treat possible causes
    Hypoxemia tamponade
    Hypovolemia tension pneumothorax
    Hyperthemiaposion/ toxin / drugs
    Hyper-/ hypokalemiathromoembolism
    Any further out of hospital interventions require medical control
    Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg
    Any further out of hospital interventions require medical control
    Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg
  • Alogrithm For Pediatric Tachycardia With Poor Perfusion
    Assess and supports ABC’s
    NO
    • Initial CPR
    • See pulselessalogrithm
    Pulse Present?
    YES
    QRS duration normal for age(app. &gt; 0.08 sec)
    • Provide oxygen or ventilation as needed
    • Attach monitor
    QRS duration normal for age(app. &lt; 0.08 sec)
    Evaluate the tachycardia
    • 12 lead ECG if practical
    • Evaluate QRS duration
    Evaluate the tachycardia
    Probable venticular Tachycardia
    • Immediate Cardioversion
    • 0.5 to 1.0 j/kg (consider sedation do not delay cardioversion)
    Probable supraventicular tachycardia
    • History incompatible
    • P-wave absent/ abnormal
    • HR not variable with activity
    • Abrupt rate changes
    • Infant : rate usually >220 bpm
    • Children: rate usually >180 bpm
    Probable sinus tachycardia
    • History compatible
    • P-wave present/Normal
    • HR often varies with activity
    • Variable RR with constant PR
    • Infant : rate usually <220 bpm
    • Children: rate usually <180 bpm
    Consider alternative Medication
    Lidocane 1mg/ kg IV bolus (wide complex only)
    Immediate cardioversion
    • Attempt cardioversion with 0.5 to 1.0j/kg (may increase to 2j/kg if initial dose is ineffective)
    • Use sedation if possible
    • Sedation must not delay cardioversion
    OR
    ImmediatelV/lO adenosine
    • Adenosine: use if lV access immediately available
    • Dose: Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg)
    • May double and repeat dose once (max 2nd dose of 12 mg)
    • Technique: use rapid bolus technique
    Consider Vagal Maneuvers
    (no delay)
    During evaluation
    • Provide oxygen and ventilation as needed
    • Conform continuous monitor
    • Medical control consultation
    • Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg
    Identify and treat possible causes
    Hypoxemia tamponade
    Hypovolemia tension pneumothorax
    Hyperthemiaposion/ toxin / drugs
    Hyper-/ hypokalemiathromoembolism
  • Alogrithm For Pediatric Tachycardia With Poor Perfusion
    Assess and supports ABC’s
    Assess and supports ABC’s
    NO
    • Initial CPR
    • See pulselessalogrithm
    Pulse Present?
    Pulse Present?
    YES
    QRS duration normal for age(app. &gt; 0.08 sec)
    • Provide oxygen or ventilation as needed
    • Attach monitor
    • Provide oxygen or ventilation as needed
    • Attach monitor
    QRS duration normal for age(app. &lt; 0.08 sec)
    Evaluate the tachycardia
    Evaluate the tachycardia
    • 12 lead ECG if practical
    • Evaluate QRS duration
    • 12 lead ECG if practical
    • Evaluate QRS duration
    Evaluate the tachycardia
    Probable venticular Tachycardia
    • Immediate Cardioversion
    • 0.5 to 1.0 j/kg (consider sedation do not delay cardioversion)
    Probable venticular Tachycardia
    • Immediate Cardioversion
    • 0.5 to 1.0 j/kg (consider sedation do not delay cardioversion)
    Probable supraventicular tachycardia
    • History incompatible
    • P-wave absent/ abnormal
    • HR not variable with activity
    • Abrupt rate changes
    • Infant : rate usually >220 bpm
    • Children: rate usually >180 bpm
    Probable sinus tachycardia
    • History compatible
    • P-wave present/Normal
    • HR often varies with activity
    • Variable RR with constant PR
    • Infant : rate usually <220 bpm
    • Children: rate usually <180 bpm
    Consider alternative Medication
    Lidocane 1mg/ kg IV bolus (wide complex only)
    Consider alternative Medication
    Lidocane 1mg/ kg IV bolus (wide complex only)
    Immediate cardioversion
    • Attempt cardioversion with 0.5 to 1.0j/kg (may increase to 2j/kg if initial dose is ineffective)
    • Use sedation if possible
    • Sedation must not delay cardioversion
    OR
    ImmediatelV/lO adenosine
    • Adenosine: use if lV access immediately available
    • Dose: Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg)
    • May double and repeat dose once (max 2nd dose of 12 mg)
    • Technique: use rapid bolus technique
    Consider Vagal Maneuvers
    (no delay)
    During evaluation
    • Provide oxygen and ventilation as needed
    • Conform continuous monitor
    • Medical control consultation
    • Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg
    Identify and treat possible causes
    Hypoxemia tamponade
    Hypovolemia tension pneumothorax
    Hyperthemiaposion/ toxin / drugs
    Hyper-/ hypokalemiathromoembolism
    During evaluation
    • Provide oxygen and ventilation as needed
    • Conform continuous monitor
    • Medical control consultation
    • Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg
    Identify and treat possible causes
    Hypoxemia tamponade
    Hypovolemia tension pneumothorax
    Hyperthemiaposion/ toxin / drugs
    Hyper-/ hypokalemiathromoembolism
  • Ventricular Fibrillation
    Rapid and irregular ventricular arrhythmia
    Low amplitude QRS
    primary form or from degeneration of unstable SVT
    Rare in children
    MI, post-op, myocarditis, severe hypoxia, long QT syndrome
    Digitalis and quinidine toxicity, catecholamines
  • V-fib
    Presents with pulse less cardiac arrest
    Fatal dysrhythmia. Death if untreated/uncorrected
    Thump on chest may occasionally restore sinus rhythm
    Treatment: immediate defibrillation, CPR
  • Alogrithm For Pediatric Pulseless Arrest
    • Assess and supports ABC’s
    • Provide 100% oxygen
    • Attach monitor
    VF/ VT
    Access rhythm ECG
    PEA/ Aystole
    Attempt defibrillation
    • Upto 3 times if needed
    • Initially 2 j/kg, 2 to 4 j/kg, 4 j/kg
    Epinephrine
    • lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
    • Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)
    During CPR
    Attempt / verify
    Endotracheal intubation and vascular access
    Check
    • Electrode position and contact
    • Paddle position and contact
    Give
    • Epinephrine every 3 to 5 min( consider high doses for for second and subsequent doses)
    Consider alternative medications
    • Vasopressors
    • Antiarrhythics
    • Bicarbonate
    Identify and treat causes
    • Hypoxemia
    • Hypovalemia
    • Hypothermia
    • Hyperkalemia/ hypokalemia and metabolic disorders
    • Tamponade
    • Tension pneumothorax
    • Toxins/poisons/drugs
    • Thromoboembolism
    Epinephrine
    • lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
    • Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)
    Attempt defibrillation with 4J/kg within 30 to 60 sec after each medication
    • Pattern should be CPR-drug-shock (repeat) ore CPR-drug-shock-shock-shock (repeat)
    Continue CPR upto 3 min.
    Antiarrythmic
    • Lidocane: 1mg/kg bolus / lV/lO/ET
    Attempt defibrillation with 4J/kg within 30 to 60 sec after each medication
    • Pattern should be CPR-drug-shock (repeat) ore CPR-drug-shock-shock-shock (repeat)
  • Alogrithm For Pediatric Pulseless Arrest
    • Assess and supports ABC’s
    • Provide 100% oxygen
    • Attach monitor
    • Assess and supports ABC’s
    • Provide 100% oxygen
    • Attach monitor
    VF/ VT
    VF/ VT
    Access rhythm ECG
    Access rhythm ECG
    PEA/ Aystole
    PEA/ Aystole
    Attempt defibrillation
    • Upto 3 times if needed
    • Initially 2 j/kg, 2 to 4 j/kg, 4 j/kg
    During CPR
    Attempt / verify
    Endotracheal intubation and vascular access
    Check
    • Electrode position and contact
    • Paddle position and contact
    Give
    • Epinephrine every 3 to 5 min( consider high doses for second and subsequent doses)
    Consider alternative medications
    • Vasopressors
    • Antiarrhythics
    • Bicarbonate
    Identify and treat causes
    • Hypoxemia
    • Hypovalemia
    • Hypothermia
    • Hyperkalemia/ hypokalemia and metabolic disorders
    • Tamponade
    • Tension pneumothorax
    • Toxins/poisons/drugs
    • Thromoboembolism
    Attempt defibrillation
    • Upto 3 times if needed
    • Initially 2 j/kg, 2 to 4 j/kg, 4 j/kg
    Epinephrine
    • lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
    • Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)
    Epinephrine
    • lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
    • Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)
    During CPR
    Attempt / verify
    Endotracheal intubation and vascular access
    Check
    • Electrode position and contact
    • Paddle position and contact
    Give
    • Epinephrine every 3 to 5 min( consider high doses for for second and subsequent doses)
    Consider alternative medications
    • Vasopressors
    • Antiarrhythics
    • Bicarbonate
    Identify and treat causes
    • Hypoxemia
    • Hypovalemia
    • Hypothermia
    • Hyperkalemia/ hypokalemia and metabolic disorders
    • Tamponade
    • Tension pneumothorax
    • Toxins/poisons/drugs
    • Thromoboembolism
    Epinephrine
    • lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
    • Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)
    Epinephrine
    • lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
    • Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)
    Attempt defibrillation with 4J/kg within 30 to 60 sec after each medication
    • Pattern should be CPR-drug-shock (repeat) ore CPR-drug-shock-shock-shock (repeat)
    Attempt defibrillation with 4J/kg within 30 to 60 sec after each medication
    • Pattern should be CPR-drug-shock (repeat) ore CPR-drug-shock-shock-shock (repeat)
    Continue CPR upto 3 min.
    Continue CPR upto 3 min.
    Antiarrythmic
    • Lidocane: 1mg/kg bolus / lV/lO/ET
    Antiarrythmic
    • Lidocane: 1mg/kg bolus / lV/lO/ET
    Attempt defibrillation with 4J/kg within 30 to 60 sec after each medication
    • Pattern should be CPR-drug-shock (repeat) or CPR-drug-shock-shock-shock (repeat)
    Attempt defibrillation with 4J/kg within 30 to 60 sec after each medication
    • Pattern should be CPR-drug-shock (repeat) ore CPR-drug-shock-shock-shock (repeat)
  • V-fib
    Anti-arrhythmic drugs indicated if defib. Ineffective or fib. recurs
    After recovery from fib. Search for underlying cause
    Ablation in WPW syndrome
    If no correctable abnormality identified, ICD indicated b/c of inc. risk of sudden death
  • Q
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  • Curious Minds = Successful Minds
  • qUiZ
  • 3
  • 2
  • 1
  • What is sinus rhythm?
    When each P-wave is followed by QRS- complex
    When each QRS-complex is preceded by P-wave
    Normal P-wave and PR interval
    All of above
    Q
  • Q:
    This is the ECG of a 2yr old girl presented with history of vomiting and fast heart rate
    What two abnormalities are shown up on ECG?
    What is most likely diagnosis?
    Three possible therapeutic procedure?
  • A
    Tachycardia(Heart rate 214/min)
    No P-wave
    Supraventricular Tachycardia
    Carotid sinus message
    Submerge face in cold water or put an ice bag on face
    lV Adenosine
  • This is the ECG of six year old boy referred to the output patient clinic with a heart murmur
    What three abnormalities are shown in ECG
    What is diagnosis?
    Name two complications which may arise?
    Q:
  • A
    Short PR interval
    Wide QRS
    Delta Waves
    Wolf parkinson-White-Syndrome
    Supraventricular tachycardia
    Heart block
  • Q:
    What is diagnosis?
    What treatment is required in a asymptomatic patient without underlying heart disease if these disappear with exercise?
  • A
    PVC
    No Treatment
  • Q:
    What is diagnosis?
    What is immediate treatment?
  • A
    Venticular fib.
    Defibrillation
  • Comments & Suggestions