2. Normal ECGs in Pediatrics
• The normal ECG changes through
development of the cardiac conduction
system and evolving hemodynamics.
• Essential to understand normal before
interpretation of abnormal rhythm.
4. Arrhythmia Analysis
May suspect arrhythmia with:
• Irregular heart rate
• Inappropriate rate for age
• Unexplained heart failure
• Known association of systemic or cardiac disease
• Symptoms: syncope, palpitations, chest pain
• Family history of arrhythmia or sudden death
5. Stable or Unstable?
Fast or Slow? Fast or Slow?
Wide or Narrow? Pulse or No Pulse? Pacing
Atropine
Adrenaline
Isoproterenol
Pacing
Atropine
Adrenaline
Isoproterenol
Consider CPR
Shock
Unsynchronized
2-4 j/kg
Shock
Synchronized
0.5-2 j/kg
SVT/VT VT/VFSVT
VT
Aberrated SVT
Regular or Irregular?
Vagal Maneuvers
Adenosine
(therapeutic or diagnostic)
Lidocaine
Synchronized
cardioversion
Rate Control
Consider CV.
ECG!
6. Unstable Tachycardias
• Cardioversion will generally be indicated.
• Document rhythm and treatment with ECG.
Limb leads (I, II and II) and
rhythm strips may be aqeduate.
• If patient has a pulse:
synchronized cardioversion 0.5-2 j/kg.
• No pulse (VT/VF):
unsynchronized cardioversion 2-4 j/kg.
7. Unstable Bradycardias
• Document rhythm and determine nature of
bradycardia
• Pacing: external or esophageal
• Atropine
• Adrenaline
• Isoproterenol
8. Sinus Node Dysfunction
• Rarely congenital.
• Seen in association with atrial surgeries:
Mustard/Senning, Fontan, ASD repair.
• Therapy for symptomatic patients: pacing.
9. First Degree AV Block
• Stable prolonged PR interval.
• Can be seen as normal variant.
• Possible causes:
Increased vagal tone
Medications
Non-sinus atrial rhythm
Conduction system disease or trauma
10. Type I (Wenckebach): Progressive lengthening of
PR interval until non-conducted beat, with subsequent
resetting of short PR. Causes grouped beats. Can be a
normal variant, especially in sleep.
11. Second Degree AVB-Type II
Abrupt failure of AV conduction without prior PR
prolongation. May progress to complete heart block.
13. Congenital Complete Heart
Block
• Diagnosis in fetus :
85% born alive if normal fetal echo
85% fetal death if structural heart disease
• Diagnosis in infants :
85% survive beyond adolescence.
• Associated with maternal SLE, often asymptomatic.
15. Third Degree AV Block -
Management
• Initial: CPR, atropine, adrenergic agents,
temporary pacing (transcutaneous or transvenous)
may be indicated if patient symptomatic.
• Permanent pacing indicated for symptomatic CHB
that is not expected to recover.
• Many infectious causes of CHB will recover with
appropriate antimicrobial therapy.
17. Normal QRS tachycardias
• More accurate term than narrow
• Re-entrant or Automatic?
Include:
• Reciprocating
• Primary Atrial
• Automatic Junctional
21. Termination of re-entrant SVT
• Vagal maneuvers (ice bag to face in infants,
Valsalva maneuvers in older children.)
• Adenosine
• If SVT reinitiates or does not respond,
consider procainamide, esmolol or
verapamil (only beyond infancy).
22. Adenosine
• Slow or block conduction at the AV node.
• Slow or block conduction at sinus node.
• Very short acting.
• Do not refrigerate.
• Rapid IV bolus 0.1 mg/kg with rapid flush to
follow, both needles in hub of IV or with three-
way stopcock, via proximal IV.
• Look for cough, flushing, change in ECG to
indicate proper administration.
23. Adenosine effects
• None or transient slowing:
Sinus tachycardia or EAT
Inadequate dose or failed administration.
• Flutter waves/atrial fibrillation revealed.
• Sudden termination:
Re-entrant rhythm involving AV node.
-Can resume almost immediately.
25. Further Management
Patient/parent education: arrhythmia
recognition and vagal maneuvers.
Medication: beta blockers, verapamil in older
patients, digoxin less effective.
Digoxin and verapamil are contraindicated in
preexcited patients.
28. Management of A-fib/flutter
• Termination: Rule out atrial thrombus
Ca++ Channel blockade for rate control
Synchronized cardioversion
Ibutilide/Pacing
• Chronic therapy: Consider anticoagulation
Anti-arrhythmics
Anti-tachycardia pacing
Radiofrequency ablation (a-flutter)
29. Ectopic Atrial Tachycardia
• Automatic foci within the atrium.
• Chronic, often incessant (risk of
tachycardiomyopathy).
• Can be difficult to distinguish from sinus
tachycardia due to mild elevation in rate and
subtle alterations in P wave morphology.
Management: anti-arrhythmics, ablation.
32. Wide QRS Tachycardias
• Supraventricular tachycardias with aberrant
conduction to the ventricle.
• Ventricular tachycardias.
Must assume all wide QRS tachycardias are
ventricular in origin until proven otherwise!
34. Stable Wide QRS Tachycardia
Regular Irregular
May try Adenosine first
Consider Lidocaine and
Procainamide
Do not use Adenosine:
May be pre-excited Afib
Always have cardioversion available before
administration of any medication.
Sedation/amnestic essential when cardioverting.
12 lead ECG
35. Aberrantly Conducted SVT
• Tachycardias with fixed or functional
bundle branch block.
• Must have 1:1 AV relationship
• Preexcited tachycardias:
Antedromic reciprocating tachycardias
Antedromic tachycardia via Mahaim
Bystander accessory pathways
40. Chronic Management of VT
• Required for sustained VT, symptomatic
patients.
• Will vary depending of type of VT.
• Consider pediatric cardiology consultation.
• Therapies include medication, surgical
interventions, ablation, and implantable
cardioverter defibrillators.
