DJORGENMORRIS

1. Dysrhythmias, Drugs,
Drips, and Defibrillation
Pediatric Considerations
Terri M. Repasky MSN, RN, CEN, EMT-P
Clinical Nurse Specialist - Emergency

2. Dysrhythmias
• Rhythm disturbances are an uncommon
cause of cardiovascular arrest in children
• In pediatrics we use three classes of
rhythms

3. Rhythm group by pulse rate
• Slow pulse = bradyarrythmia
• Fast pulse = tachyarrhythmia
• Absent pulse = collapse rhythms

4. Slow Pulse

5. Fast Narrow Pulse

6. Fast Wide Pulse

7. NO Pulse

8. Things to Consider
• Is the patient stable or unstable ?
• Is the patient’s condition causing the rhythm
OR is the rhythm causing the condition?
• Is the rhythm causing the patient to be
unstable ?

9. Assessment of
Cardiovascular Function
• Ventilation and
Oxygenation
• Heart Rate
• End-organ perfusion
• Peripheral pulses
• Skin signs
• LOC
• Blood pressure

10. Pulses  Blood Pressure
• Compensated Shock
• Hypotensive Shock

11. Blood Pressure
Cardiac Output = Heart Rate x Stroke Volume

12. Back to Pulses
• Is it fast, slow, or absent?
• Is perfusion compromised?
• Are the ventricular complexes wide or
narrow?
• Is there a diagnostic pattern to the EKG?

13. Sinus Tachycardia

14. Supraventricular Tachycardia

15. Fast Pulse
Narrow Ventricular Complex
• Sinus
Tachycardia
• Supraventricular
Tachycardia

16. Fast Pulse
Narrow Ventricular Complex
• Sinus
Tachycardia
• Possible history of
fever, pain, volume
loss (diarrhea,
vomiting, bleeding,
trauma), anxiety, meds
• Supraventricular
Tachycardia
• Nonspecific history of
irritability, lethargy,
poor feeding,
tachypnea, sweating,
pallor or hypothermia

17. Fast Pulse
• Tachycardia
appropriate for the
clinical condition
• Tachycardia
excessive for the
clinical condition

18. Fast Pulse
• Tachycardia
appropriate for the
clinical condition
• Sinus Tachycardia
(ST)
• Tachycardia
excessive for the
clinical condition
• SupraVentricular
Tachycardia
(SVT)

19. Fast Pulse
Narrow Ventricular Complex (QRS)
• Is it Supraventricular Tachycardia (SVT)
or
• Sinus Tachycardia (ST) ???

20. Fast Pulse
Narrow Ventricular Complex (QRS)
• Is it Supraventricular Tachycardia (SVT)
or
• Sinus Tachycardia (ST) ???
History and Heart Rate are big clues

21. Fast Pulse
Narrow Ventricular Complex
Heart Rate Probable SVT
> 180 Children
> 220 Infants

22. Fast Pulse
Tachycardia excessive for the clinical condition
(not Sinus Tach)
Stable, Perfusing Patient
• Narrow QRS
(probable SVT)
• Wide QRS
(probable VT)
• Vagal Maneuvers
• Adenosine
• Expert Consultation
• Amiodarone or Procainamide
• Treat possible contributing factors
• Expert Consult
• Amiodarone or Procainamide
• Treat possible contributing factors

23. Fast Pulse
Tachycardia excessive for the clinical condition
Unstable Patient, Poor Perfusion
• Narrow QRS
(probable SVT)
• Wide QRS
(probable VT)
• Synchronized
Cardioversion
• (may try Adenosine if it does
not delay electrical
cardioversion)

24. Fast Pulse
Tachycardia appropriate for the clinical condition
• Consider the cause….
• Treat the cause !

25. Slow Pulse
Stable Patient
Sinus Bradycardia Heart Blocks
• Consider the cause
– Prolonged hypoxemia
– Drugs

26. Slow Pulse
• Consider the cause:
• 6 H’s and 5 T’s
Hypovolemia Hypoxemia
“Hydrogen Ion” Hypothermia
Hypoglycemia Hyper /Hypokalemia

27. Slow Pulse
• Consider the cause:
• more H’s:
Head Injury Heart Block
Heart Transplant Heart Disease

28. Slow Pulse
• Consider the cause:
• 5 T’s
Tamponade Tension Pneumothorax
Toxins Thrombosis
Trauma

29. Slow Pulse
Unstable Patient, Poor Perfusion
• Oxygenation and Ventilation
• Chest Compressions (if heart rate still <60 despite O2 & vents)
• Epinephrine
• ? Atropine
• Pace Maker

30. Slow Pulse
• Epinephrine vs Atropine

31. NO Pulse
• Asystole
• Ventricular Fibrillation (VF)
• Pulseless Ventricular Tachycardia (VT)
• Pulseless Electrical Activity (PEA)

32. No Pulse
• CPR ? Defibrillate
• Ventilate with 100% oxygen
• IV or IO access
• Epinephrine q 3-5 minutes

33. No Pulse
Asystole or PEA
• CPR
• Ventilate with 100% oxygen
• IV or IO access
• Epinephrine q 3-5 minutes
• Treat Cause!
• Perform flat line protocol

34. No Pulse
• Flat Line Protocol
–Check Leads
–Check in a different lead
–Increase gain or size

35. No Pulse
•Consider cause:
6 H’s and 5 T’s

36. No Pulse
Pulseless Ventricular Tachycardia or Fibrillation
• CPR
• Defibrillate (as soon as available)
• Resume CPR
• Rhythm Check (Q2mins), if VF/VT
• Defibrillate
• Give Meds
• Resume CPR
• Alternate Epi with Amiodarone

37. Summary of Therapy
by Pulse Rate
Fast
(adequate perfusion)  Vagal Maneuvers, Adenosine or
Amiodarone/Procainamide
(poor perfusion)  Cardioversion
Slow  Ventilation / Oxygenation
Compressions
Epi.
Absent  CPR
VF / VT:  Defibrillation
PEA/EMD:  Identify & treat the cause
Epinephrine

38. Warning:
Treat the Patient
Not the Rhythm

39. Drugs & Drips
Fluids “Drips” are use for:
Volume Replacement &
Delivery of Medications

40. Drips: Fluids of Choice
• Isotonic Crystalloids
–Normal Saline
–Lactated Ringer’s
• What if your patient is hypoglycemic?

41. Drugs: Sites for Administration
Peripheral veins
Intraosseous
Central veins
Endotracheal

42. When would you use an IO ?

43. When would you use an IO ?
Cardiopulmonary Arrest
Shock
Intractable seizures

44. When would you use ET ?
• What drugs can you give down the ET
tube?
• L or L
• E A
• A N
• N E

45. How do I do that?
• Dilute the drug with 3-5 ml of NS
• Instill directly into tube
• Deliver positive pressure breaths
• Or Insert a catheter into ET tube
• Instill drug via catheter
• Flush with 3-5 ml of normal saline
• Deliver positive pressure breaths
1
2

46. Drugs Dosages: ET / IO
• IO: same dose as IV
• ET:
– Epinephrine dose is 10 times greater
0.1 mg/kg (use 1:1,000 strength)
– Other drug are increased 2-3 times IV dose

47. “ Defib.”
Joules per kilogram

48. Post Arrest Shock
Optimize Ventilation
and Oxygenation
Titrate O2 saturation
to 94% - 99%
Advanced Airway
Waveform
Capnography
Treat shock
&
Contributing Factors

49. Review
• Dysrhythmias - fast, slow, none
• Drugs - Oxygen, Epinephrine
• Drips - Normal Saline
• Defibrillation - rare but know how !

50. • Questions ????