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Evaluation & Management of a Child with Arrhythmias<br />By<br />Dr.SaimaBashir<br />Post Graduate Trainee<br />Pediatric ...
Definition<br />Cardiac arrhythmia (also dysrhythmia) is a term for any of a large and heterogeneous group of conditions i...
Classification Of Arrhythmias<br />Tachycardia<br />Bradycardia<br />Sinus tachycardia<br />SVT<br />Vent. Fib<br />Vent. ...
Causes Of Arrhythmias<br />Congenital<br />Acquired<br />In structurally normal/ abnormal heart<br />Congenital metabolic ...
Why Basic Understandning Of Arrhytmias Is Important???<br />Major risk of an arrhythmia is either severe bradycardia or ta...
Symptoms<br />Range from <br />Completely asymptomatic <br />Loss of consciousness<br />Sudden cardiac death<br />In infan...
Examination	<br />GPE<br />Pulse__ irregular, feeble, inc./dec. rate, absent<br />Tachypnea<br />B.P __ Normal, hypotensio...
Respiratory system<br />Bil. Crepts (pulm. edema)<br />GIT<br />Hepatomegaly<br />CNS<br />Normal<br />Hpotonia<br />
Evaluation Of The Child With An Arrhythmia<br />History<br />Symptoms<br />Frequency and length of episode<br />Onset and ...
Evaluation Of The Child With An Arrhythmia<br />Physical examination<br />ABC’s<br />Hemodynamic stability <br />Adjunctiv...
Evaluation Of The Child With An Arrhythmia<br />Patient with arrhythmia<br />Ensure ABCs<br />Absent<br />Asystole<br />As...
Evaluation Of The Child With An Arrhythmia<br />Assess Pulse<br />Irregular <br />Fast<br />Slow<br />P- Wave<br />PR-Inte...
Evaluation Of The Child With An Arrhythmia<br />Assess Pulse<br />Irregular <br />Fast<br />Slow<br />P- Wave <br />QRS- C...
 Normal QRS-     Complex</li></ul>Normal<br /><ul><li>Normal but different shape QRS complex
P- Wave Present</li></ul>Wide  QRS- complex<br />Sinus Arrythmia<br />PVC<br />PAC<br />Atrial Fib.<br />
Evaluation Of The Child With An Arrhythmia<br />Assess Pulse<br />Irregular <br />Fast<br />Slow<br />QRS- Complex<br />QS...
 low amplitude QRS- Complex</li></ul>Sinus trachycardia<br />SVT<br />Atrial flutter<br />V- Tech<br />V- Fib.<br />
Pediatric Dysrhythmias<br />Reproduced from Zitelli’s Atlas of Pediatric physical diagnosis, 2007, pg 140.<br />
Sinus Rhythm<br />Every QRS complex is preceded by a P wave and every P wave must be followed by a QRS (the opposite occur...
Sinus Arrhythmia <br />Most common irregularity of heart rhythm seen in children<br />Normal variant<br />Reflects healthy...
Sinus Arrhythmia <br />Normal phasic variation of heart rate with respiration<br />Variable P-P intervals<br />No treatmen...
Wandering Atrial Pacemaker<br />normal QRS complex<br /> Change in P-wave configuration <br />
Atrial pacemaker shifts intermittently from sinus node to another atrial site<br />Normal variant<br />May also be seen in...
Premature Atrial Contraction<br /> Ectopic focus in atria or AV node<br /> Narrow but normal QRS<br /> Normal P wave<br />
Isolated PAC’s<br />Premature atrial contractions<br />Benign in absence of underlying heart disease<br />Common in newbor...
Premature Ventricular Contraction<br />Ectopic beat activates ventricle before the wave of depolarization from normal sinu...
Premature Ventricular Contraction<br />Not very commonly seen in children<br />Incidence of 0.3 to 2.2 %<br />Myocarditis<...
unifocal, <br />disappear with exercise, and <br />associated with structurally and functionally normal heart, then consid...
PVC’s Evaluation<br />Indicated if<br />Two or more PVCs in a row<br />Multifocal origin<br />Increased vent. Ectopic acti...
PVC’s Evaluation<br />12 lead EKG, Echocardiogram<br />Perhaps Holter monitoring<br />Brief exercise in office to see if e...
IV lignocaine – 1st line drug
Amiodarone in refractory cases with hemodyanamic compromise</li></li></ul><li>Evaluation Of The Child With An Arrhythmia<b...
Sinus Bradycardia<br />Normal P wave axis and P-R interval<br /> HR &lt; 5th percentile for age<br />
Sinus Bradycardia<br />Athletic individuals (normal)<br />Increased ICP                 <br />hyperkalemia<br />vagal stim...
Long Q-T Syndrome<br />Bradycardia<br />Prolonged QT interva<br /> Notched T- wave<br />
 Long Q-T Syndrome<br />Genetic abnormality of vent. Repolarization<br />50% cases familial<br />Romano Ward syndrome – co...
 Long Q-T Syndrome<br />Diagnostic criteria:<br />QTc &gt;0.47 __ indicative<br />QTc &gt;0.44 __ suggestive<br />Notched ...
 Long Q-T Syndrome<br />Treatment:<br />Beta blockers __ to blunt heart response to exercise<br />Pacemaker if drug induce...
 Sick Sinus Syndrome<br />Result of abnormality in sinus node or atrial conduction pathway or both<br />Arrhythmias includ...
Alogrithm For Pediatric Bradycardia<br /><ul><li>Assess and supports ABC’s
Provide 100% oxygen
Attach monitor
Vascular Access</li></ul>Yes <br />No<br />Is bradycardia causing severe cardiorespiratoycompromist??<br />Poor perfusion,...
Support ABCs
Consider tranfer or transport to ALS facility</li></ul>Perform chest compression<br />If despite oxygenation and ventilati...
Paddle position and contact</li></ul>Give<br /><ul><li>Epinephrine every 3 to 5 min( consider high doses for for second an...
Hypothermia
Heart block
Heart transplant
Toxins/poisons/drugs</li></ul>Epinephrine<br /><ul><li>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</li></ul>Atropine: 0.02mg/kg<br />(min.dose 0.1mg)<br /><ul><li>May be repeated onc...
Alogrithm For Pediatric Bradycardia<br /><ul><li>Assess and supports ABC’s
Provide 100% oxygen
Attach monitor
Vascular Access
Assess and supports ABC’s
Provide 100% oxygen
Attach monitor
Vascular Access</li></ul>Is bradycardia causing severe cardiorespiratoycompromist??<br />(Poor perfusion,  hypotension, re...
Support ABCs
Consider tranfer or transport to ALS facility
Observe
Support ABCs
Consider tranfer or transport to ALS facility</li></ul>Perform chest compression<br />If despite oxygenation and ventilati...
Paddle position and contact</li></ul>Give<br /><ul><li>Epinephrine every 3 to 5 min( consider high doses for for second an...
Hypothermia
Heart block
Heart transplant
Toxins/poisons/drugs</li></ul>During CPR<br />Attempt / verify<br />Endotracheal intubation and vascular access<br />Check...
Paddle position and contact</li></ul>Give<br /><ul><li>Epinephrine every 3 to 5 min( consider high doses for for second an...
Hypothermia
Heart block
Heart transplant
Toxins/poisons/drugs</li></ul>Epinephrine<br /><ul><li>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</li></ul>Epinephrine<br /><ul><li>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</li></ul>Atropine: 0.02mg/kg<br />(min.dose 0.1mg)<br /><ul><li>May be repeated onc...
AV Nodal Block First- Degree  Heart Block<br />Delayed conduction through AV node<br /> Prolongation of PR interval<br />
First degree AV Block<br />Commonly seen (up to 6% normal neonates)<br />PR interval is greater than upper limits of norma...
80-220 msec in  young children and adults</li></ul>Generally does not cause bradycardia since AV conduction remains intact...
AV Nodal Block First-Degree Heart Block<br />Usually asymptomatic<br />Diseases that can be associated with first degree A...
Lyme disease,
CHD (ASD, Ebstein’s anomaly),
cardiomyopathy,
post-cardiac surgery,
normal children
Hypothermia
Electrolyte disturbances</li></li></ul><li>AV Nodal Block First-Degree Heart Block<br />Drugs: Digitalis toxicity<br />Tre...
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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.

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Evaluation & Management Of Child With Arrhythmias

  1. 1.
  2. 2. Evaluation & Management of a Child with Arrhythmias<br />By<br />Dr.SaimaBashir<br />Post Graduate Trainee<br />Pediatric medicine unit-I<br />Mayo Hospital Lahore<br />
  3. 3. Definition<br />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.<br />
  4. 4. Classification Of Arrhythmias<br />Tachycardia<br />Bradycardia<br />Sinus tachycardia<br />SVT<br />Vent. Fib<br />Vent. Tachy<br />Atril fib.<br />Atrial flutter<br />Sinus bradycardia<br />Heart block<br />Irregular<br />Sinus arrhythmia<br />PAC<br />PVC<br />
  5. 5. Causes Of Arrhythmias<br />Congenital<br />Acquired<br />In structurally normal/ abnormal heart<br />Congenital metabolic disorders of mitochondria<br />SLE <br />Rheumatic fever<br />Myocarditis<br />Toxin (diphtheria)<br />Pro-arrhythmic or anti-arrhythmic drugs<br />Surgical correction of CHD<br />
  6. 6. Why Basic Understandning Of Arrhytmias Is Important???<br />Major risk of an arrhythmia is either severe bradycardia or tachycadiadec. cardiac output <br /> degeneration into more severe arrhythmias (vent. fib.) <br />To be aware of arrhythmias that occur in otherwise healthy children<br />
  7. 7. Symptoms<br />Range from <br />Completely asymptomatic <br />Loss of consciousness<br />Sudden cardiac death<br />In infants <br />Lethargy<br />Poor feeding<br />Irritability<br />Cardiac failure<br />Underlying congenital <br />heart disease<br />In children<br />Palpitation<br />Syncope<br />Dizziness<br />Chronic fatigue<br />Shortness of breath<br />Chest discomfort<br />
  8. 8. Examination <br />GPE<br />Pulse__ irregular, feeble, inc./dec. rate, absent<br />Tachypnea<br />B.P __ Normal, hypotension<br />JVP __ raised in CCF<br /> Cyanosis<br />Pallor<br />CVS<br />Precordial bulge<br />Right ventricular heave<br />Gallop<br />Murmur<br />
  9. 9. Respiratory system<br />Bil. Crepts (pulm. edema)<br />GIT<br />Hepatomegaly<br />CNS<br />Normal<br />Hpotonia<br />
  10. 10. Evaluation Of The Child With An Arrhythmia<br />History<br />Symptoms<br />Frequency and length of episode<br />Onset and triggers<br />Any underlying disease<br />Medications<br />Triggering factor<br />Used for underlying cardiac disease<br />
  11. 11. Evaluation Of The Child With An Arrhythmia<br />Physical examination<br />ABC’s<br />Hemodynamic stability <br />Adjunctive testing<br />12-Lead ECG<br />Holter<br />External event recorders<br />Exercise testing<br />
  12. 12. Evaluation Of The Child With An Arrhythmia<br />Patient with arrhythmia<br />Ensure ABCs<br />Absent<br />Asystole<br />Assess rhythm<br />V FIB<br />Pulseless V Tach<br />PEA<br />Absent<br />Assess pulse<br />Present<br />Irregular<br />Fast<br />Slow<br />Narrow QRS<br />Wide QRS<br />Sinus Bradycardia<br />AVN Block<br />Sick Sinus<br />Sinus arrhythmia<br />Atrial FIB<br />PAC +/- Block<br />PVC<br />Sinus Tachycardia<br />SVT (PAT)<br />Atrial flutter<br />V TACH<br />V FIB<br />
  13. 13. Evaluation Of The Child With An Arrhythmia<br />Assess Pulse<br />Irregular <br />Fast<br />Slow<br />P- Wave<br />PR-Interval<br />Prolonged PR-Interval<br />Normal <br />Heart- block<br />Sinus Bradycardia<br />
  14. 14. Evaluation Of The Child With An Arrhythmia<br />Assess Pulse<br />Irregular <br />Fast<br />Slow<br />P- Wave <br />QRS- Complex<br /><ul><li>Fibrillatory (Multiple P- Wave )
  15. 15. Normal QRS- Complex</li></ul>Normal<br /><ul><li>Normal but different shape QRS complex
  16. 16. P- Wave Present</li></ul>Wide QRS- complex<br />Sinus Arrythmia<br />PVC<br />PAC<br />Atrial Fib.<br />
  17. 17. Evaluation Of The Child With An Arrhythmia<br />Assess Pulse<br />Irregular <br />Fast<br />Slow<br />QRS- Complex<br />QS Wide<br />QRS Normal<br />P- Wave<br />P- Wave<br />Absent or Atriovent dissociation <br />Present<br />Absent<br />Sawtooth<br />Appearance<br /><ul><li> No P- Wave
  18. 18. low amplitude QRS- Complex</li></ul>Sinus trachycardia<br />SVT<br />Atrial flutter<br />V- Tech<br />V- Fib.<br />
  19. 19. Pediatric Dysrhythmias<br />Reproduced from Zitelli’s Atlas of Pediatric physical diagnosis, 2007, pg 140.<br />
  20. 20. Sinus Rhythm<br />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). <br />The P wave morphology and axis must be normal and <br />PR interval will usually be normal for that age<br />
  21. 21. Sinus Arrhythmia <br />Most common irregularity of heart rhythm seen in children<br />Normal variant<br />Reflects healthy interaction between autonomic respiratory and cardiac control activity in CNS<br />Heart rate increases during inspiration and decreases during expiration<br />
  22. 22. Sinus Arrhythmia <br />Normal phasic variation of heart rate with respiration<br />Variable P-P intervals<br />No treatment needed<br />
  23. 23. Wandering Atrial Pacemaker<br />normal QRS complex<br /> Change in P-wave configuration <br />
  24. 24. Atrial pacemaker shifts intermittently from sinus node to another atrial site<br />Normal variant<br />May also be seen in CNS disturbances like subarachnoid hemorrhage<br />Wandering Atrial Pacemaker<br />
  25. 25. Premature Atrial Contraction<br /> Ectopic focus in atria or AV node<br /> Narrow but normal QRS<br /> Normal P wave<br />
  26. 26. Isolated PAC’s<br />Premature atrial contractions<br />Benign in absence of underlying heart disease<br />Common in newborn period<br />Early p wave, sometimes with different morphology than a sinus p wave<br />Can be either:<br />Not conducted to ventricle, apparent pause<br />Conducted to ventricle with aberrant or widened QRS complex ( careful not to mix up with PVC’s)<br />
  27. 27. Premature Ventricular Contraction<br />Ectopic beat activates ventricle before the wave of depolarization from normal sinus node <br />Abnormally wide QRS complex appears early which are not preceded by P-wave<br /> T-wave points in the direction opposite to QRS complex<br />Bigeminy, trigeminy, couplet<br />Unifocal, multifocal<br /> Three or more successive PVCs are termed as ventricular tachycardia<br />
  28. 28. Premature Ventricular Contraction<br />Not very commonly seen in children<br />Incidence of 0.3 to 2.2 %<br />Myocarditis<br />cardiomyopathy<br />CHD <br />hypokalemia<br />Hypoxia<br />Drugs:Digitalis toxicity, catecholamines, theophylline, caffeine, anesthetics, Class I and III anti-arrhythmics<br />myocardial injury <br />long QT syndrome <br />hypomagnesemia<br />
  29. 29. unifocal, <br />disappear with exercise, and <br />associated with structurally and functionally normal heart, then considered benign, no therapy needed<br />PVC’s<br />
  30. 30. PVC’s Evaluation<br />Indicated if<br />Two or more PVCs in a row<br />Multifocal origin<br />Increased vent. Ectopic activity with exercise<br />R on T phenomenon (PVC occurs on preceding beat)<br />Presence of underlying heart disease<br />
  31. 31. PVC’s Evaluation<br />12 lead EKG, Echocardiogram<br />Perhaps Holter monitoring<br />Brief exercise in office to see if ectopy suppressed or more frequent<br />Treatment: <br /><ul><li>Correction of underlying condition
  32. 32. IV lignocaine – 1st line drug
  33. 33. Amiodarone in refractory cases with hemodyanamic compromise</li></li></ul><li>Evaluation Of The Child With An Arrhythmia<br />Assess Pulse<br />Irregular <br />Fast<br />Slow<br />P- Wave<br />PR-Interval<br />Prolonged PR-Interval<br />Normal <br />Heart- block<br />Sinus Bradycardia<br />
  34. 34. Sinus Bradycardia<br />Normal P wave axis and P-R interval<br /> HR &lt; 5th percentile for age<br />
  35. 35. Sinus Bradycardia<br />Athletic individuals (normal)<br />Increased ICP <br />hyperkalemia<br />vagal stimulation <br />hypothermia <br />Drugs: digoxin, beta-blockers, clonidine, opiods, sedative-hypnotics, amiodarone<br />Treatment: address underlying cause<br />hypoxia <br />hypercalcemia<br />hypothyroidism <br />long QT syndrome<br />
  36. 36. Long Q-T Syndrome<br />Bradycardia<br />Prolonged QT interva<br /> Notched T- wave<br />
  37. 37. Long Q-T Syndrome<br />Genetic abnormality of vent. Repolarization<br />50% cases familial<br />Romano Ward syndrome – common form of LQTS<br />Drugs causing LQTS: terfenadine, cisapride, droperidol<br />Clinical manifestation:<br />Syncope induced by exercise, fright, startle<br />Some events occur during sleep<br />Seizures<br />Palpitation<br />Cardiac arrest (10%)<br />
  38. 38. Long Q-T Syndrome<br />Diagnostic criteria:<br />QTc &gt;0.47 __ indicative<br />QTc &gt;0.44 __ suggestive<br />Notched T- wave<br />Low heart rate for age<br />Syncope<br />Family H/O LQTS or unexplained sudden death<br />Investigation<br />12 lead ECG<br />Holter Monitoring<br />Exercise testing<br />
  39. 39. Long Q-T Syndrome<br />Treatment:<br />Beta blockers __ to blunt heart response to exercise<br />Pacemaker if drug induces profound bradycardia<br />Implanted cardiac defibrillators <br />Continuous syncope<br />No response to drug treatment<br />Experienced cardiac arrest<br />
  40. 40. Sick Sinus Syndrome<br />Result of abnormality in sinus node or atrial conduction pathway or both<br />Arrhythmias include sinus bradycardia, blocks, sinus arrest with junctional escape, paroxysmal atrialtachycadia.<br />Most common after surgical correction of CHD<br />Clinical manifestations depend on heart rate<br />Asymptomatic <br />Dizziness<br />Syncope<br />Treatment: pacemaker therapy in symptomatic patient<br />
  41. 41. Alogrithm For Pediatric Bradycardia<br /><ul><li>Assess and supports ABC’s
  42. 42. Provide 100% oxygen
  43. 43. Attach monitor
  44. 44. Vascular Access</li></ul>Yes <br />No<br />Is bradycardia causing severe cardiorespiratoycompromist??<br />Poor perfusion, hypotension, respiratory difficulty. Altered conciousness<br /><ul><li>Observe
  45. 45. Support ABCs
  46. 46. Consider tranfer or transport to ALS facility</li></ul>Perform chest compression<br />If despite oxygenation and ventilation<br />HR &lt;60/min in infant or child and poor systemic perfusion<br />During CPR<br />Attempt / verify<br />Endotracheal intubation and vascular access<br />Check<br /><ul><li>Electrode position and contact
  47. 47. Paddle position and contact</li></ul>Give<br /><ul><li>Epinephrine every 3 to 5 min( consider high doses for for second and subsequent doses) epinephrine or dopamine infusion</li></ul>Identify and treat causes<br /><ul><li>Hypoxemia
  48. 48. Hypothermia
  49. 49. Heart block
  50. 50. Heart transplant
  51. 51. Toxins/poisons/drugs</li></ul>Epinephrine<br /><ul><li>lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
  52. 52. Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)
  53. 53. May repeat every 3-5 min. at same dose</li></ul>Atropine: 0.02mg/kg<br />(min.dose 0.1mg)<br /><ul><li>May be repeated once</li></ul>Give atropine 1st for bradycardia due to suspected increase vagal tone or primary AV block<br />Consider cardiac pacing<br />If pulseless arrest develops see pediatrics pulseless arrest algorithm<br />
  54. 54. Alogrithm For Pediatric Bradycardia<br /><ul><li>Assess and supports ABC’s
  55. 55. Provide 100% oxygen
  56. 56. Attach monitor
  57. 57. Vascular Access
  58. 58. Assess and supports ABC’s
  59. 59. Provide 100% oxygen
  60. 60. Attach monitor
  61. 61. Vascular Access</li></ul>Is bradycardia causing severe cardiorespiratoycompromist??<br />(Poor perfusion, hypotension, respiratory difficulty. Altered conciousness )<br />Yes <br />No<br />Is bradycardia causing severe cardiorespiratoycompromist??<br />Poor perfusion, hypotension, respiratory difficulty. Altered conciousness<br />Perform chest compression<br />If despite oxygenation and ventilation<br />HR &lt;60/min in infant or child and poor systemic perfusion<br /><ul><li>Observe
  62. 62. Support ABCs
  63. 63. Consider tranfer or transport to ALS facility
  64. 64. Observe
  65. 65. Support ABCs
  66. 66. Consider tranfer or transport to ALS facility</li></ul>Perform chest compression<br />If despite oxygenation and ventilation<br />HR &lt;60/min in infant or child and poor systemic perfusion<br />During CPR<br />Attempt / verify<br />Endotracheal intubation and vascular access<br />Check<br /><ul><li>Electrode position and contact
  67. 67. Paddle position and contact</li></ul>Give<br /><ul><li>Epinephrine every 3 to 5 min( consider high doses for for second and subsequent doses) epinephrine or dopamine infusion</li></ul>Identify and treat causes<br /><ul><li>Hypoxemia
  68. 68. Hypothermia
  69. 69. Heart block
  70. 70. Heart transplant
  71. 71. Toxins/poisons/drugs</li></ul>During CPR<br />Attempt / verify<br />Endotracheal intubation and vascular access<br />Check<br /><ul><li>Electrode position and contact
  72. 72. Paddle position and contact</li></ul>Give<br /><ul><li>Epinephrine every 3 to 5 min( consider high doses for for second and subsequent doses) epinephrine or dopamine infusion</li></ul>Identify and treat causes<br /><ul><li>Hypoxemia
  73. 73. Hypothermia
  74. 74. Heart block
  75. 75. Heart transplant
  76. 76. Toxins/poisons/drugs</li></ul>Epinephrine<br /><ul><li>lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
  77. 77. Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)
  78. 78. May repeat every 3-5 min. at same dose</li></ul>Epinephrine<br /><ul><li>lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
  79. 79. Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)
  80. 80. May repeat every 3-5 min. at same dose</li></ul>Atropine: 0.02mg/kg<br />(min.dose 0.1mg)<br /><ul><li>May be repeated once</li></ul>Atropine: 0.02mg/kg<br />(min.dose 0.1mg)<br /><ul><li>May be repeated once</li></ul>Give atropine 1st for bradycardia due to suspected increase vagal tone or primary AV block<br />Give atropine 1st for bradycardia due to suspected increase vagal tone or primary AV block<br />Consider cardiac pacing<br />Consider cardiac pacing<br />If pulseless arrest develops see pediatrics pulseless arrest algorithm<br />If pulseless arrest develops see pediatrics pulseless arrest algorithm<br />
  81. 81. AV Nodal Block First- Degree Heart Block<br />Delayed conduction through AV node<br /> Prolongation of PR interval<br />
  82. 82. First degree AV Block<br />Commonly seen (up to 6% normal neonates)<br />PR interval is greater than upper limits of normal for a given age<br />PR interval is age and rate dependent<br /><ul><li>70-170 msec in newborns is normal
  83. 83. 80-220 msec in young children and adults</li></ul>Generally does not cause bradycardia since AV conduction remains intact<br />
  84. 84. AV Nodal Block First-Degree Heart Block<br />Usually asymptomatic<br />Diseases that can be associated with first degree AV block:<br /><ul><li>Acute rheumatic fever
  85. 85. Lyme disease,
  86. 86. CHD (ASD, Ebstein’s anomaly),
  87. 87. cardiomyopathy,
  88. 88. post-cardiac surgery,
  89. 89. normal children
  90. 90. Hypothermia
  91. 91. Electrolyte disturbances</li></li></ul><li>AV Nodal Block First-Degree Heart Block<br />Drugs: Digitalis toxicity<br />Treatment: Address underlying cause<br />Isolated finding- benign, no treatment and no follow up needed<br />
  92. 92. Second-Degree Heart Block:Mobitz Type I - Wenckebach<br />P<br />Progressive lengthening of PR interval until a QRS is not conducted (ventricular contraction does not occur)<br />
  93. 93. Second-Degree Heart Block:Mobitz Type I - Wenckebach<br />Does not usually progress to complete heart block<br />Diseases that can be associated<br /><ul><li>Myocarditis,
  94. 94. cardiomyopathy,
  95. 95. CHD,
  96. 96. cardiac surgery,
  97. 97. MI,
  98. 98. normal children at times of increased parasympathetic activity</li></ul>Drugs: digitalis toxicity, beta-blocker toxicity<br />Treatment: address underlying cause<br />
  99. 99. Second-Degree Heart Block:Mobitz Type Il <br /> Constant PR interval before a skipped ventricular conduction<br />
  100. 100. Block below the AV node in the bundle of His<br />Not found in normal children, usually those with structural disease or post-op<br />May progress to complete heart block<br />May require pacemaker<br />Second-Degree Heart Block:Mobitz Type Il <br />
  101. 101. Third-Degree Heart Block: Complete<br /> Complete dissociation of atrial and ventricular conduction <br /> P wave and PR interval normal<br />Junctional pacemaker – narrow QRS<br />Ventricular pacemaker – wide QRS<br /> Rate 30 – 50 beats/min <br />
  102. 102. Third-Degree Heart Block: Complete<br />Congenital: maternal lupus or CT disease, CHD (L-TGA or abnormal AV septum)<br />Acquired: post-op, acute rheumatic fever, Lyme carditis, myocarditis, cardiomyopathy, MI<br />Slower the heart rate, and wide QRS escape rhythms place into high risk group<br />May need implantable pacemaker: significant bradycardias, syncope, exercise intolerance, ventricular dysrhythmias, or ventricular arrhythmias, structural disease<br />Possible acute treatment: isoproterenol<br />
  103. 103. Sinus Tachycardia<br /> Normal sinus rhythm<br /> HR &gt;95th percentile for age<br /> Usually &lt; 230 beats/min<br />
  104. 104. Sinus Tachycardia<br />Hypovolemia<br />Anemia<br />fever <br />CHF <br />Drugs: Beta-agonists, aminophylline, atropine<br />Treatment: address underlying cause.<br />shock <br />Sepsis<br />anxiety <br />
  105. 105. Supraventricular Tachycardia<br />&gt; 230 beats/min<br /> Narrow QRS<br /> P waves not visible<br />
  106. 106.
  107. 107. Supraventricular tachycardia<br />Most common abnormal tachycardia seen in pediatric practice<br />Most common arrhythmia requiring treatment in pediatric population<br />Most frequent age presentation: <br /><ul><li>1st 3 months of life,
  108. 108. 2nd peaks @ 8-10 and in adolescense</li></ul>Causes:<br /><ul><li>Idiopathic
  109. 109. CHD (Ebstein’s anomaly, transposition)</li></li></ul><li>SVT - Presentation<br />Paroxysmal, sudden onset & offset <br />Rates of SVT vary with age<br />Overall average rate for all ages: 235 bpm<br />P waves difficult to define, but 1:1 with QRS<br />Important to differentiate from sinus tachycardia<br />
  110. 110. SVT - Presentation<br />Older kids can describe a sensation of a fast heart rate, palpitations, or chest tightness<br />Hemodynamic compromise (CCF) in newborns and those with structural heart disease<br />
  111. 111. SVT -Treatment<br />Goal: <br /><ul><li>identify unstable patients,
  112. 112. differentiate from sinus tachycardia, and
  113. 113. terminate the rhythm </li></li></ul><li>
  114. 114. Alogrithm For Pediatric Tachycardia With Adequate Perfusion<br /><ul><li>Assess and supports ABC’s (assess signs of circulation and pulse)
  115. 115. Provide oxygen and ventilation as needed
  116. 116. Attach monitor
  117. 117. Evaluate 12 lead ECG if pratical</li></ul> ≤0.08 sec<br />&gt; 0.08 sec<br />Probable ventricular tachycardia<br />Evaluate Rhythm<br />What is QRS Duration?<br />Probable supraventicular tachycardia<br /><ul><li>History incompatible
  118. 118. P-wave absent/ abnormal
  119. 119. HR not variable with activity
  120. 120. Abrupt rate changes
  121. 121. Infant : rate usually >220 bpm
  122. 122. Children: rate usually >180 bpm</li></ul>Consider alternative Medication<br />Lidocane 1mg/ kg IV bolus (wide complex only)<br />Probable sinus tachycardia<br /><ul><li>History compatible
  123. 123. P-wave present/Normal
  124. 124. HR often varies with activity
  125. 125. Variable RR with constant PR
  126. 126. Infant : rate usually <220 bpm
  127. 127. Children: rate usually <180 bpm</li></ul>During evaluation<br /><ul><li>Provide oxygen and ventilation as needed
  128. 128. Conform continuous monitor
  129. 129. Medical control consultation
  130. 130. Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg</li></ul>Consider Vagal Maneuvers<br />(no delay)<br />Establish vascular access<br /><ul><li>Consider adenosine 0.1mg/ kg lV/ lO (maximum first dose of 6 mg)
  131. 131. May double and repeat dose once (maximum 2nd dose of 12 mg)
  132. 132. Techniques: use rapid bolus technique</li></ul>Identify and treat possible causes<br />Hypoxemia tamponade<br />Hypovolemia tension pneumothorax<br />Hyperthemiaposion/ toxin / drugs<br />Hyper-/ hypokalemiathromoembolism<br />Any further out of hospital interventions require medical control<br />Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg<br />
  133. 133. Alogrithm For Pediatric Tachycardia With Adequate Perfusion<br />Assess and supports ABC’s (assess signs of circulation and pulse)<br />Provide oxygen and ventilation as needed<br />Attach monitor<br />Evaluate 12 lead ECG if pratical<br /><ul><li>Assess and supports ABC’s (assess signs of circulation and pulse)
  134. 134. Provide oxygen and ventilation as needed
  135. 135. Attach monitor
  136. 136. Evaluate 12 lead ECG if pratical</li></ul> ≤0.08 sec<br />&gt; 0.08 sec<br />Probable ventricular tachycardia<br />Evaluate Rhythm<br />Evaluate Rhythm<br />What is QRS Duration?<br />What is QRS Duration?<br />Probable supraventicular tachycardia<br /><ul><li>History incompatible
  137. 137. P-wave absent/ abnormal
  138. 138. HR not variable with activity
  139. 139. Abrupt rate changes
  140. 140. Infant : rate usually >220 bpm
  141. 141. Children: rate usually >180 bpm</li></ul>Probable supraventicular tachycardia<br /><ul><li>History incompatible
  142. 142. P-wave absent/ abnormal
  143. 143. HR not variable with activity
  144. 144. Abrupt rate changes
  145. 145. Infant : rate usually >220 bpm
  146. 146. Children: rate usually >180 bpm</li></ul>Consider alternative Medication<br />Lidocane 1mg/ kg IV bolus (wide complex only)<br />Probable sinus tachycardia<br /><ul><li>History compatible
  147. 147. P-wave present/Normal
  148. 148. HR often varies with activity
  149. 149. Variable RR with constant PR
  150. 150. Infant : rate usually <220 bpm
  151. 151. Children: rate usually <180 bpm</li></ul>During evaluation<br />Provide oxygen and ventilation as needed<br />Conform continuous monitor<br />Medical control consultation<br />Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg<br />During evaluation<br /><ul><li>Provide oxygen and ventilation as needed
  152. 152. Conform continuous monitor
  153. 153. Medical control consultation
  154. 154. Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg</li></ul>Consider Vagal Maneuvers<br />(no delay)<br />Consider Vagal Maneuvers<br />(no delay)<br />Establish vascular access<br />Consider adenosine 0.1mg/ kg lV/ lO (maximum first dose of 6 mg)<br />May double and repeat dose once (maximum 2nd dose of 12 mg)<br />Techniques: use rapid bolus technique<br />Identify and treat possible causes<br />Hypoxemia Tamponade<br />Hypovolemia Tension pneumothorax<br />HyperthemiaPosion/ toxin / drugs<br />Hyper-/ hypokalemiaThromoembolism<br />Establish vascular access<br /><ul><li>Consider adenosine 0.1mg/ kg lV/ lO (maximum first dose of 6 mg)
  155. 155. May double and repeat dose once (maximum 2nd dose of 12 mg)
  156. 156. Techniques: use rapid bolus technique</li></ul>Identify and treat possible causes<br />Hypoxemia Tamponade<br />Hypovolemia Tension pneumothorax<br />HyperthemiaPosion/ toxin / drugs<br />Hyper-/ hypokalemiaThromoembolism<br />Any further out of hospital interventions require medical control<br />Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg<br />Any further out of hospital interventions require medical control<br />Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg<br />
  157. 157.
  158. 158. Alogrithm For Pediatric Tachycardia With Poor Perfusion<br />Assess and supports ABC’s <br />NO<br /><ul><li>Initial CPR
  159. 159. See pulselessalogrithm</li></ul>Pulse Present?<br />YES<br />QRS duration normal for age(app. &gt; 0.08 sec)<br /><ul><li>Provide oxygen or ventilation as needed
  160. 160. Attach monitor</li></ul>QRS duration normal for age(app. &lt; 0.08 sec)<br />Evaluate the tachycardia<br /><ul><li>12 lead ECG if practical
  161. 161. Evaluate QRS duration</li></ul>Evaluate the tachycardia<br />Probable venticular Tachycardia<br /><ul><li>Immediate Cardioversion
  162. 162. 0.5 to 1.0 j/kg (consider sedation do not delay cardioversion)</li></ul>Probable supraventicular tachycardia<br /><ul><li>History incompatible
  163. 163. P-wave absent/ abnormal
  164. 164. HR not variable with activity
  165. 165. Abrupt rate changes
  166. 166. Infant : rate usually >220 bpm
  167. 167. Children: rate usually >180 bpm</li></ul>Probable sinus tachycardia<br /><ul><li>History compatible
  168. 168. P-wave present/Normal
  169. 169. HR often varies with activity
  170. 170. Variable RR with constant PR
  171. 171. Infant : rate usually <220 bpm
  172. 172. Children: rate usually <180 bpm</li></ul>Consider alternative Medication<br />Lidocane 1mg/ kg IV bolus (wide complex only)<br />Immediate cardioversion<br /><ul><li>Attempt cardioversion with 0.5 to 1.0j/kg (may increase to 2j/kg if initial dose is ineffective)
  173. 173. Use sedation if possible
  174. 174. Sedation must not delay cardioversion</li></ul>OR<br />ImmediatielV/lO adenosine<br /><ul><li>Adenosine: use if lV access immediately available
  175. 175. Dose: Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg)
  176. 176. May double and repeat dose once (max 2nd dose of 12 mg)
  177. 177. Technique: use rapid bolus technique </li></ul>Consider Vagal Maneuvers<br />(no delay)<br />During evaluation<br /><ul><li>Provide oxygen and ventilation as needed
  178. 178. Conform continuous monitor
  179. 179. Medical control consultation
  180. 180. Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg</li></ul>Identify and treat possible causes<br />Hypoxemia tamponade<br />Hypovolemia tension pneumothorax<br />Hyperthemiaposion/ toxin / drugs<br />Hyper-/ hypokalemiathromoembolism<br />
  181. 181. Alogrithm For Pediatric Tachycardia With Poor Perfusion<br />Assess and supports ABC’s <br />Assess and supports ABC’s <br />NO<br /><ul><li>Initial CPR
  182. 182. See pulselessalogrithm</li></ul>Pulse Present?<br />Pulse Present?<br />YES<br />QRS duration normal for age(app. &gt; 0.08 sec)<br /><ul><li>Provide oxygen or ventilation as needed
  183. 183. Attach monitor
  184. 184. Provide oxygen or ventilation as needed
  185. 185. Attach monitor</li></ul>QRS duration normal for age(app. &lt; 0.08 sec)<br />Evaluate the tachycardia<br /><ul><li>12 lead ECG if practical
  186. 186. Evaluate QRS duration
  187. 187. 12 lead ECG if practical
  188. 188. Evaluate QRS duration</li></ul>Evaluate the tachycardia<br />Evaluate the tachycardia<br />Probable venticular Tachycardia<br /><ul><li>Immediate Cardioversion
  189. 189. 0.5 to 1.0 j/kg (consider sedation do not delay cardioversion)</li></ul>Probable supraventicular tachycardia<br /><ul><li>History incompatible
  190. 190. P-wave absent/ abnormal
  191. 191. HR not variable with activity
  192. 192. Abrupt rate changes
  193. 193. Infant : rate usually >220 bpm
  194. 194. Children: rate usually >180 bpm</li></ul>Probable supraventicular tachycardia<br /><ul><li>History incompatible
  195. 195. P-wave absent/ abnormal
  196. 196. HR not variable with activity
  197. 197. Abrupt rate changes
  198. 198. Infant : rate usually >220 bpm
  199. 199. Children: rate usually >180 bpm</li></ul>Probable sinus tachycardia<br /><ul><li>History compatible
  200. 200. P-wave present/Normal
  201. 201. HR often varies with activity
  202. 202. Variable RR with constant PR
  203. 203. Infant : rate usually <220 bpm
  204. 204. Children: rate usually <180 bpm</li></ul>Consider alternative Medication<br />Lidocane 1mg/ kg IV bolus (wide complex only)<br />Immediate cardioversion<br /><ul><li>Attempt cardioversion with 0.5 to 1.0j/kg (may increase to 2j/kg if initial dose is ineffective)
  205. 205. Use sedation if possible
  206. 206. Sedation must not delay cardioversion</li></ul>OR<br />ImmediatielV/lO adenosine<br /><ul><li>Adenosine: use if lV access immediately available
  207. 207. Dose: Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg)
  208. 208. May double and repeat dose once (max 2nd dose of 12 mg)
  209. 209. Technique: use rapid bolus technique </li></ul>Immediate cardioversion<br /><ul><li>Attempt cardioversion with 0.5 to 1.0j/kg (may increase to 2j/kg if initial dose is ineffective)
  210. 210. Use sedation if possible
  211. 211. Sedation must not delay cardioversion</li></ul>OR<br />ImmediatielV/lO adenosine<br /><ul><li>Adenosine: use if lV access immediately available
  212. 212. Dose: Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg)
  213. 213. May double and repeat dose once (max 2nd dose of 12 mg)
  214. 214. Technique: use rapid bolus technique </li></ul>Consider Vagal Maneuvers<br />(no delay)<br />Consider Vagal Maneuvers<br />(no delay)<br />During evaluation<br /><ul><li>Provide oxygen and ventilation as needed
  215. 215. Conform continuous monitor
  216. 216. Medical control consultation
  217. 217. Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg</li></ul>Identify and treat possible causes<br />Hypoxemia Tamponade<br />Hypovolemia Tension pneumothorax<br />HyperthemiaPosion/ toxin / drugs<br />Hyper-/ hypokalemiaThromoembolism<br />During evaluation<br /><ul><li>Provide oxygen and ventilation as needed
  218. 218. Conform continuous monitor
  219. 219. Medical control consultation
  220. 220. Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg</li></ul>Identify and treat possible causes<br />Hypoxemia tamponade<br />Hypovolemia tension pneumothorax<br />Hyperthemiaposion/ toxin / drugs<br />Hyper-/ hypokalemiathromoembolism<br />
  221. 221. SVT -Treatment<br />Need post conversion EKG – identify those with WPW syndrome ( 25 % pts with SVT)<br />Will also need an echo – identify structural problems<br />Medications (to prevent recurrance)<br /><ul><li>Digoxin and beta blockers as first line
  222. 222. Flecainide, sotalol, amiodarone</li></ul>Observation and expectant management<br />Radiofrequency catheter ablation<br /><ul><li>Frontline treatment
  223. 223. Very effective
  224. 224. Cutoff points usually are 5 y.o. and 15 kg, unless severe SVT</li></li></ul><li>Supraventricular TachycardiaWPW<br /><ul><li> Accessory pathway establishes cyclic pattern of signal reentry
  225. 225. Impulse arrives at ventricle rapidly without delay at the AV node
  226. 226. Independent of AV node
  227. 227. Most common cause of nonsinus tachycardia in children</li></li></ul><li>Wolff-Parkinson-White Syndrome<br /><ul><li>Delta wave
  228. 228. slurred upstroke of QRS
  229. 229. Reflects pre-excitation
  230. 230. Short PR- interval
  231. 231. Wide QRS complex</li></li></ul><li>Atrial Flutter<br /> Dilated Atria, intraatrial surgery<br /> Digitalis toxicity<br />Post-Fontan procedure patients <br />Atrial rate 250-350 beats/min<br />Sawtooth (no discrete P waves)<br /> Normal QRS complex<br />
  232. 232. Atrial Flutter<br />Chronic atrial flutter:<br />Inc. risk of thromboembolism and stroke<br />Anticoagulation<br />Radiofrequency ablation in CHD in older child<br />Management<br />Emergency:<br />Vagal maneuver<br />adenosine<br />Synchronized cardioversion0.5-2 J/kg<br />Overdrive pacing<br />Long term:<br />Digoxin+/- B- Blockers<br />Ablation<br />
  233. 233. Atrial Fibrillation<br />Atrial rate 350-600 beats/min<br />Atrial waves are totally irregular<br /> P wave vary in size and shape from beat to beat<br /> vent. response is irregularly irregular <br />QRS complexes are usually normal<br />
  234. 234. Atrial Fibrillation<br />Much less common<br />Chronically stretched atria<br />Intra atrial surgery<br />Left atrial enlargement due to mitral valve insufficiency<br />WPW syndrome<br />Thyrotoxicosis<br />Pulm. Embolism<br />Pericarditis<br />familial<br />
  235. 235. Atrial Fibrillation<br />Treatment:<br />Restore normal heart rate by digitalization (avoided in WPW syndrome)<br />Restore normal rhythm by adding quinidine/procainamide/DC cardioversion<br />Prevention of thromboembolic phenomenon and stoke by warfarin<br />
  236. 236. Ventricular Tachycardia<br />120-150 beats/min<br /> Wide QRS<br /> 3 or more consecutive beats from the ventricle (PVCs)<br />85% have abnormal cardiac anatomy<br />Metabolic abnormalities<br />Drugs/toxins: tricyclic antidepressants<br />
  237. 237. V-Tach<br />Associated with <br />Myocarditis<br />Anomalous origin of coron. A. <br />Rt. Vent. Dysplasia<br />Mitral valve prolapse<br />CMP<br />LQTS<br />WPW synd.<br />Drugs(cocaine, amphetamine)<br />
  238. 238. V-Tach<br />Treatment: IV lidocaine, procainamide, amiodarone<br />If critically ill: synchronized cardioversion<br />Long term: meds, ablation, or defibrillator<br />
  239. 239.
  240. 240. Alogrithm For Pediatric Tachycardia With Adequate Perfusion<br /><ul><li>Assess and supports ABC’s (assess signs of circulation and pulse)
  241. 241. Provide oxygen and ventilation as needed
  242. 242. Attach monitor
  243. 243. Evaluate 12 lead ECG if practical</li></ul>0.08 sec<br />0.08 sec<br />Probable ventricular tachycardia<br />Evaluate Rhythm<br />What is QRS Duration?<br />Probable supraventicular tachycardia<br /><ul><li>History incompatible
  244. 244. P-wave absent/ abnormal
  245. 245. HR not variable with activity
  246. 246. Abrupt rate changes
  247. 247. Infant : rate usually >220 bpm
  248. 248. Children: rate usually >180 bpm</li></ul>Consider alternative Medication<br />Lidocane 1mg/ kg IV bolus (wide complex only)<br />Probable sinus tachycardia<br /><ul><li>History compatible
  249. 249. P-wave present/Normal
  250. 250. HR often varies with activity
  251. 251. Variable RR with constant PR
  252. 252. Infant : rate usually <220 bpm
  253. 253. Children: rate usually <180 bpm</li></ul>During evaluation<br /><ul><li>Provide oxygen and ventilation as needed
  254. 254. Conform continuous monitor
  255. 255. Medical control consultation
  256. 256. Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg</li></ul>Consider Vagal Maneuvers<br />(no delay)<br />Establish vascular access<br /><ul><li>Consider adenosine 0.1mg/ kg lV/ lO (maximum first dose of 6 mg)
  257. 257. May double and repeat dose once (maximum 2nd dose of 12 mg)
  258. 258. Techniques: use rapid bolus technique</li></ul>Identify and treat possible causes<br />Hypoxemia tamponade<br />Hypovolemia tension pneumothorax<br />Hyperthemiaposion/ toxin / drugs<br />Hyper-/ hypokalemiathromoembolism<br />Any further out of hospital interventions require medical control<br />Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg<br />
  259. 259. Alogrithm For Pediatric Tachycardia With Adequate Perfusion<br />Assess and supports ABC’s (assess signs of circulation and pulse)<br />Provide oxygen and ventilation as needed<br />Attach monitor<br />Evaluate 12 lead ECG if pratical<br /><ul><li>Assess and supports ABC’s (assess signs of circulation and pulse)
  260. 260. Provide oxygen and ventilation as needed
  261. 261. Attach monitor
  262. 262. Evaluate 12 lead ECG if practical</li></ul>0.08 sec<br />0.08 sec<br />Probable ventricular tachycardia<br />What is QRS Duration?<br />Probable ventricular tachycardia<br />Evaluate Rhythm<br />What is QRS Duration?<br />Probable supraventicular tachycardia<br /><ul><li>History incompatible
  263. 263. P-wave absent/ abnormal
  264. 264. HR not variable with activity
  265. 265. Abrupt rate changes
  266. 266. Infant : rate usually >220 bpm
  267. 267. Children: rate usually >180 bpm</li></ul>Consider alternative Medication<br />Lidocane 1mg/ kg IV bolus (wide complex only)<br />Lidocane 1mg/ kg IV bolus (wide complex only)<br />Consider alternative Medication<br />Probable sinus tachycardia<br /><ul><li>History compatible
  268. 268. P-wave present/Normal
  269. 269. HR often varies with activity
  270. 270. Variable RR with constant PR
  271. 271. Infant : rate usually <220 bpm
  272. 272. Children: rate usually <180 bpm</li></ul>During evaluation<br /><ul><li>Provide oxygen and ventilation as needed
  273. 273. Conform continuous monitor
  274. 274. Medical control consultation
  275. 275. Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg</li></ul>During evaluation<br /><ul><li>Provide oxygen and ventilation as needed
  276. 276. Conform continuous monitor
  277. 277. Medical control consultation
  278. 278. Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg</li></ul>Consider Vagal Maneuvers<br />(no delay)<br />Establish vascular access<br /><ul><li>Consider adenosine 0.1mg/ kg lV/ lO (maximum first dose of 6 mg)
  279. 279. May double and repeat dose once (maximum 2nd dose of 12 mg)
  280. 280. Techniques: use rapid bolus technique</li></ul>Identify and treat possible causes<br />Hypoxemia Tamponade<br />Hypovolemia Tension pneumothorax<br />HyperthemiaPosion/ toxin / drugs<br />Hyper-/ hypokalemiaThromoembolism<br />Identify and treat possible causes<br />Hypoxemia tamponade<br />Hypovolemia tension pneumothorax<br />Hyperthemiaposion/ toxin / drugs<br />Hyper-/ hypokalemiathromoembolism<br />Any further out of hospital interventions require medical control<br />Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg<br />Any further out of hospital interventions require medical control<br />Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg<br />
  281. 281.
  282. 282. Alogrithm For Pediatric Tachycardia With Poor Perfusion<br />Assess and supports ABC’s <br />NO<br /><ul><li>Initial CPR
  283. 283. See pulselessalogrithm</li></ul>Pulse Present?<br />YES<br />QRS duration normal for age(app. &gt; 0.08 sec)<br /><ul><li>Provide oxygen or ventilation as needed
  284. 284. Attach monitor</li></ul>QRS duration normal for age(app. &lt; 0.08 sec)<br />Evaluate the tachycardia<br /><ul><li>12 lead ECG if practical
  285. 285. Evaluate QRS duration</li></ul>Evaluate the tachycardia<br />Probable venticular Tachycardia<br /><ul><li>Immediate Cardioversion
  286. 286. 0.5 to 1.0 j/kg (consider sedation do not delay cardioversion)</li></ul>Probable supraventicular tachycardia<br /><ul><li>History incompatible
  287. 287. P-wave absent/ abnormal
  288. 288. HR not variable with activity
  289. 289. Abrupt rate changes
  290. 290. Infant : rate usually >220 bpm
  291. 291. Children: rate usually >180 bpm</li></ul>Probable sinus tachycardia<br /><ul><li>History compatible
  292. 292. P-wave present/Normal
  293. 293. HR often varies with activity
  294. 294. Variable RR with constant PR
  295. 295. Infant : rate usually <220 bpm
  296. 296. Children: rate usually <180 bpm</li></ul>Consider alternative Medication<br />Lidocane 1mg/ kg IV bolus (wide complex only)<br />Immediate cardioversion<br /><ul><li>Attempt cardioversion with 0.5 to 1.0j/kg (may increase to 2j/kg if initial dose is ineffective)
  297. 297. Use sedation if possible
  298. 298. Sedation must not delay cardioversion</li></ul>OR<br />ImmediatelV/lO adenosine<br /><ul><li>Adenosine: use if lV access immediately available
  299. 299. Dose: Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg)
  300. 300. May double and repeat dose once (max 2nd dose of 12 mg)
  301. 301. Technique: use rapid bolus technique </li></ul>Consider Vagal Maneuvers<br />(no delay)<br />During evaluation<br /><ul><li>Provide oxygen and ventilation as needed
  302. 302. Conform continuous monitor
  303. 303. Medical control consultation
  304. 304. Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg</li></ul>Identify and treat possible causes<br />Hypoxemia tamponade<br />Hypovolemia tension pneumothorax<br />Hyperthemiaposion/ toxin / drugs<br />Hyper-/ hypokalemiathromoembolism<br />
  305. 305. Alogrithm For Pediatric Tachycardia With Poor Perfusion<br />Assess and supports ABC’s <br />Assess and supports ABC’s <br />NO<br /><ul><li>Initial CPR
  306. 306. See pulselessalogrithm</li></ul>Pulse Present?<br />Pulse Present?<br />YES<br />QRS duration normal for age(app. &gt; 0.08 sec)<br /><ul><li>Provide oxygen or ventilation as needed
  307. 307. Attach monitor
  308. 308. Provide oxygen or ventilation as needed
  309. 309. Attach monitor</li></ul>QRS duration normal for age(app. &lt; 0.08 sec)<br />Evaluate the tachycardia<br />Evaluate the tachycardia<br /><ul><li>12 lead ECG if practical
  310. 310. Evaluate QRS duration
  311. 311. 12 lead ECG if practical
  312. 312. Evaluate QRS duration</li></ul>Evaluate the tachycardia<br />Probable venticular Tachycardia<br /><ul><li>Immediate Cardioversion
  313. 313. 0.5 to 1.0 j/kg (consider sedation do not delay cardioversion)</li></ul>Probable venticular Tachycardia<br /><ul><li>Immediate Cardioversion
  314. 314. 0.5 to 1.0 j/kg (consider sedation do not delay cardioversion)</li></ul>Probable supraventicular tachycardia<br /><ul><li>History incompatible
  315. 315. P-wave absent/ abnormal
  316. 316. HR not variable with activity
  317. 317. Abrupt rate changes
  318. 318. Infant : rate usually >220 bpm
  319. 319. Children: rate usually >180 bpm</li></ul>Probable sinus tachycardia<br /><ul><li>History compatible
  320. 320. P-wave present/Normal
  321. 321. HR often varies with activity
  322. 322. Variable RR with constant PR
  323. 323. Infant : rate usually <220 bpm
  324. 324. Children: rate usually <180 bpm</li></ul>Consider alternative Medication<br />Lidocane 1mg/ kg IV bolus (wide complex only)<br />Consider alternative Medication<br />Lidocane 1mg/ kg IV bolus (wide complex only)<br />Immediate cardioversion<br /><ul><li>Attempt cardioversion with 0.5 to 1.0j/kg (may increase to 2j/kg if initial dose is ineffective)
  325. 325. Use sedation if possible
  326. 326. Sedation must not delay cardioversion</li></ul>OR<br />ImmediatelV/lO adenosine<br /><ul><li>Adenosine: use if lV access immediately available
  327. 327. Dose: Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg)
  328. 328. May double and repeat dose once (max 2nd dose of 12 mg)
  329. 329. Technique: use rapid bolus technique </li></ul>Consider Vagal Maneuvers<br />(no delay)<br />During evaluation<br /><ul><li>Provide oxygen and ventilation as needed
  330. 330. Conform continuous monitor
  331. 331. Medical control consultation
  332. 332. Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg</li></ul>Identify and treat possible causes<br />Hypoxemia tamponade<br />Hypovolemia tension pneumothorax<br />Hyperthemiaposion/ toxin / drugs<br />Hyper-/ hypokalemiathromoembolism<br />During evaluation<br /><ul><li>Provide oxygen and ventilation as needed
  333. 333. Conform continuous monitor
  334. 334. Medical control consultation
  335. 335. Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg</li></ul>Identify and treat possible causes<br />Hypoxemia tamponade<br />Hypovolemia tension pneumothorax<br />Hyperthemiaposion/ toxin / drugs<br />Hyper-/ hypokalemiathromoembolism<br />
  336. 336. Ventricular Fibrillation<br />Rapid and irregular ventricular arrhythmia<br />Low amplitude QRS<br /> primary form or from degeneration of unstable SVT<br />Rare in children<br /> MI, post-op, myocarditis, severe hypoxia, long QT syndrome<br /> Digitalis and quinidine toxicity, catecholamines<br />
  337. 337. V-fib<br />Presents with pulse less cardiac arrest<br />Fatal dysrhythmia. Death if untreated/uncorrected<br />Thump on chest may occasionally restore sinus rhythm<br />Treatment: immediate defibrillation, CPR<br />
  338. 338.
  339. 339. Alogrithm For Pediatric Pulseless Arrest<br /><ul><li>Assess and supports ABC’s
  340. 340. Provide 100% oxygen
  341. 341. Attach monitor</li></ul>VF/ VT<br />Access rhythm ECG<br />PEA/ Aystole<br />Attempt defibrillation<br /><ul><li>Upto 3 times if needed
  342. 342. Initially 2 j/kg, 2 to 4 j/kg, 4 j/kg</li></ul>Epinephrine<br /><ul><li>lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
  343. 343. Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)</li></ul>During CPR<br />Attempt / verify<br />Endotracheal intubation and vascular access<br />Check<br /><ul><li>Electrode position and contact
  344. 344. Paddle position and contact</li></ul>Give<br /><ul><li>Epinephrine every 3 to 5 min( consider high doses for for second and subsequent doses)</li></ul>Consider alternative medications<br /><ul><li>Vasopressors
  345. 345. Antiarrhythics
  346. 346. Bicarbonate</li></ul>Identify and treat causes<br /><ul><li>Hypoxemia
  347. 347. Hypovalemia
  348. 348. Hypothermia
  349. 349. Hyperkalemia/ hypokalemia and metabolic disorders
  350. 350. Tamponade
  351. 351. Tension pneumothorax
  352. 352. Toxins/poisons/drugs
  353. 353. Thromoboembolism</li></ul>Epinephrine<br /><ul><li>lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
  354. 354. Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)</li></ul>Attempt defibrillation with 4J/kg within 30 to 60 sec after each medication<br /><ul><li>Pattern should be CPR-drug-shock (repeat) ore CPR-drug-shock-shock-shock (repeat)</li></ul>Continue CPR upto 3 min.<br />Antiarrythmic<br /><ul><li>Lidocane: 1mg/kg bolus / lV/lO/ET</li></ul>Attempt defibrillation with 4J/kg within 30 to 60 sec after each medication<br /><ul><li>Pattern should be CPR-drug-shock (repeat) ore CPR-drug-shock-shock-shock (repeat)</li></li></ul><li>Alogrithm For Pediatric Pulseless Arrest<br /><ul><li>Assess and supports ABC’s
  355. 355. Provide 100% oxygen
  356. 356. Attach monitor
  357. 357. Assess and supports ABC’s
  358. 358. Provide 100% oxygen
  359. 359. Attach monitor</li></ul>VF/ VT<br />VF/ VT<br />Access rhythm ECG<br />Access rhythm ECG<br />PEA/ Aystole<br />PEA/ Aystole<br />Attempt defibrillation<br /><ul><li>Upto 3 times if needed
  360. 360. Initially 2 j/kg, 2 to 4 j/kg, 4 j/kg</li></ul>During CPR<br />Attempt / verify<br />Endotracheal intubation and vascular access<br />Check<br /><ul><li>Electrode position and contact
  361. 361. Paddle position and contact</li></ul>Give<br /><ul><li>Epinephrine every 3 to 5 min( consider high doses for second and subsequent doses)</li></ul>Consider alternative medications<br /><ul><li>Vasopressors
  362. 362. Antiarrhythics
  363. 363. Bicarbonate</li></ul>Identify and treat causes<br /><ul><li>Hypoxemia
  364. 364. Hypovalemia
  365. 365. Hypothermia
  366. 366. Hyperkalemia/ hypokalemia and metabolic disorders
  367. 367. Tamponade
  368. 368. Tension pneumothorax
  369. 369. Toxins/poisons/drugs
  370. 370. Thromoboembolism</li></ul>Attempt defibrillation<br /><ul><li>Upto 3 times if needed
  371. 371. Initially 2 j/kg, 2 to 4 j/kg, 4 j/kg</li></ul>Epinephrine<br /><ul><li>lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
  372. 372. Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)</li></ul>Epinephrine<br /><ul><li>lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
  373. 373. Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)</li></ul>During CPR<br />Attempt / verify<br />Endotracheal intubation and vascular access<br />Check<br /><ul><li>Electrode position and contact
  374. 374. Paddle position and contact</li></ul>Give<br /><ul><li>Epinephrine every 3 to 5 min( consider high doses for for second and subsequent doses)</li></ul>Consider alternative medications<br /><ul><li>Vasopressors
  375. 375. Antiarrhythics
  376. 376. Bicarbonate</li></ul>Identify and treat causes<br /><ul><li>Hypoxemia
  377. 377. Hypovalemia
  378. 378. Hypothermia
  379. 379. Hyperkalemia/ hypokalemia and metabolic disorders
  380. 380. Tamponade
  381. 381. Tension pneumothorax
  382. 382. Toxins/poisons/drugs
  383. 383. Thromoboembolism</li></ul>Epinephrine<br /><ul><li>lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
  384. 384. Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)</li></ul>Epinephrine<br /><ul><li>lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg)
  385. 385. Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)</li></ul>Attempt defibrillation with 4J/kg within 30 to 60 sec after each medication<br /><ul><li>Pattern should be CPR-drug-shock (repeat) ore CPR-drug-shock-shock-shock (repeat)</li></ul>Attempt defibrillation with 4J/kg within 30 to 60 sec after each medication<br /><ul><li>Pattern should be CPR-drug-shock (repeat) ore CPR-drug-shock-shock-shock (repeat)</li></ul>Continue CPR upto 3 min.<br />Continue CPR upto 3 min.<br />Antiarrythmic<br /><ul><li>Lidocane: 1mg/kg bolus / lV/lO/ET</li></ul>Antiarrythmic<br /><ul><li>Lidocane: 1mg/kg bolus / lV/lO/ET</li></ul>Attempt defibrillation with 4J/kg within 30 to 60 sec after each medication<br /><ul><li>Pattern should be CPR-drug-shock (repeat) or CPR-drug-shock-shock-shock (repeat)</li></ul>Attempt defibrillation with 4J/kg within 30 to 60 sec after each medication<br /><ul><li>Pattern should be CPR-drug-shock (repeat) ore CPR-drug-shock-shock-shock (repeat)</li></li></ul><li>V-fib<br />Anti-arrhythmic drugs indicated if defib. Ineffective or fib. recurs<br />After recovery from fib. Search for underlying cause<br />Ablation in WPW syndrome<br />If no correctable abnormality identified, ICD indicated b/c of inc. risk of sudden death<br />
  386. 386. Q<br />Q<br />?<br />?<br />?<br />Q<br />Q<br />?<br />Q<br />Q<br />?<br />?<br />?<br />?<br />?<br />?<br />?<br />Q<br />Q<br />?<br />?<br />?<br />?<br />Q<br />
  387. 387. Curious Minds = Successful Minds<br />
  388. 388. qUiZ<br />
  389. 389. 3<br />
  390. 390. 2<br />
  391. 391. 1<br />
  392. 392. What is sinus rhythm?<br />When each P-wave is followed by QRS- complex<br />When each QRS-complex is preceded by P-wave<br />Normal P-wave and PR interval<br />All of above <br />Q<br />
  393. 393. Q:<br />This is the ECG of a 2yr old girl presented with history of vomiting and fast heart rate<br />What two abnormalities are shown up on ECG?<br />What is most likely diagnosis?<br />Three possible therapeutic procedure?<br />
  394. 394. A<br />Tachycardia(Heart rate 214/min)<br /> No P-wave<br />Supraventricular Tachycardia<br />Carotid sinus message<br /> Submerge face in cold water or put an ice bag on face<br />lV Adenosine<br />
  395. 395. This is the ECG of six year old boy referred to the output patient clinic with a heart murmur<br />What three abnormalities are shown in ECG<br />What is diagnosis?<br />Name two complications which may arise?<br />Q:<br />
  396. 396. A<br />Short PR interval <br /> Wide QRS<br /> Delta Waves<br />Wolf parkinson-White-Syndrome<br />Supraventricular tachycardia<br /> Heart block<br />
  397. 397. Q:<br />What is diagnosis?<br />What treatment is required in a asymptomatic patient without underlying heart disease if these disappear with exercise?<br />
  398. 398. A<br />PVC<br />No Treatment<br />
  399. 399. Q:<br />What is diagnosis?<br />What is immediate treatment?<br />
  400. 400. A<br />Venticular fib.<br />Defibrillation<br />
  401. 401. Comments & Suggestions<br />

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