2. Pediatric dysrhythmias
Treatment not required Treatment is required
Sinus arrhythmia Supraventricular tachycardia
Wandering atrial pacemaker
Isolated premature atrial
contractions
Isolated premature
ventricular contractions
Ventricular tachycardia
First degree AV block Third degree AV block with
symptoms
Reproduced from Zitelli’s Atlas of Pediatric physical diagnosis, 2007, pg 140.
3. 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?
4. 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
6. Wandering atrial pacemaker
Atrial pacemaker shifts from sinus node to
another atrial site
Normal variant, irregular rhythm
7. Isolated PAC’s
Premature atrial contractions
Benign in absence of underlying heart dz
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)
9. Premature Ventricular Contractions (PVC’s)
Not very commonly seen in children
Incidence of 0.3 to 2.2 %
Early, wide QRS complexes
T waves in opposite direction of QRS
Unifocal PVC’s are most encountered type
Bigeminy, sinus beat followed by PVC,
repeating as a pattern, also frequently
seen
10. PVC’s
If unifocal, disappear with exercise, and
associated with structurally and functionally
normal heart, then considered benign, no
therapy needed
11. PVC’s evaluation
12 lead EKG, Echocardiogram
Perhaps Holter monitoring
Brief exercise in office to see if ectopy
suppressed or more frequent
Multifocal or paired PVC’s more worrisome
Medications usually not needed
Advise patients to avoid caffeine and other
stimulants
12. 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
13. First degree AV block
Diseases that can be associated with first
degree AV block: rheumatic fever, rubella,
mumps, hypothermia, cardiomyopathy,
electrolyte disturbances
14. 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
15. 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
16. 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
17. 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
Rapid, regular, usually narrow QRS
rhythm, originating above the ventricles
18. SVT
Figure 5-42 Supraventricular tachycardia. Note a normal QRS complex
tachycardia at a rate of 214 beats/minute without visible P waves.
19. 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
20. 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
21. SVT - Treatment
Goal: identify unstable patients, differentiate from
sinus tachycardia, and terminate the rhythm
Vagal maneuvers in stable patients
Adenosine if IV access readily available
– 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
22. SVT - Treatment
Need post conversion EKG – 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
23. Other SVT’s
A flutter, A fib, ectopic atrial tachycardia,
junctional tachycardias
Not commonly seen in pediatric patients
Adenosine does not terminate these
rhythms, originate above AV node
Treatments: procainamide, amiodarone,
cardioversion, or ablation
24. SVT - WPW
Figure 5-43 Wolff-Parkinson-White syndrome. Note the characteristic findings of a short P-R
interval, slurred upstroke of QRS (delta wave), and prolongation of the QRS interval.
25. 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
26. V-Tach
Treatment: IV lidocaine, procainamide,
amiodarone
If critically ill: synchronized cardioversion
Long term: meds, ablation, or defibrillator
27. 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
28. V-fib
Brugada syndrome – inherited arrhythmia,
autosomal dominant person goes into v-
fib, faints, dies suddenly
Treatment: defibrillator, careful screening
