This document discusses various pediatric dysrhythmias, their typical presentations, and treatment approaches. It describes that sinus arrhythmia, wandering atrial pacemaker, and isolated premature contractions are usually normal variants that do not require treatment. Supraventricular tachycardia is the most common arrhythmia requiring treatment and can often be terminated with vagal maneuvers, adenosine, or cardioversion. First degree atrioventricular block is commonly seen in neonates but generally does not cause bradycardia. Third degree atrioventricular block may require a pacemaker, especially if associated with slower heart rates or symptoms. Ventricular arrhythmias like tachycardia or fibrillation indicate serious underlying

1. Pediatric Dysrhythmias
Board Review
Dr. Sahar K.K. AttiaDr. Sahar K.K. Attia
Pediatric Specialist,KKHPediatric Specialist,KKH.
May ,2015

3. Pediatric dysrhythmias
Treatment not requiredTreatment not required TreatmentTreatment isis requiredrequired
Sinus arrhythmiaSinus arrhythmia SupraventricularSupraventricular
tachycardiatachycardia
Wandering atrialWandering atrial
pacemakerpacemaker
Isolated premature atrialIsolated premature atrial
contractionscontractions
Isolated prematureIsolated premature
ventricular contractionsventricular contractions
Ventricular tachycardiaVentricular tachycardia
First degree AV blockFirst degree AV block Third degree AV blockThird degree AV block
with symptomswith symptoms

4. 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?

5. 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. Sinus arrhythmia

7. Wandering atrial pacemaker
• Atrial pacemaker shifts from sinus node
to another atrial site.
• Normal variant, irregular rhythm

8. Isolated PAC’sIsolated 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. Isolated PAC’sIsolated PAC’s

10. Premature Ventricular ContractionsPremature Ventricular Contractions
(PVC’s)(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.

11. PVC’s
• If unifocal, disappear with exercise, and
associated with structurally and functionally
normal heart, then considered benign, no
therapy needed.

12. 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

13. 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

14. First degree AV blockFirst degree AV block
• Diseases that can be associated with first
degree AV block:
- rheumatic fever, rubella, mumps,
hypothermia, cardiomyopathy, electrolyte
disturbances

15. 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

16. 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

17. 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

18. 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

19. SVT
Figure 5-42 Supraventricular tachycardia
- Note a normal QRS complex tachycardia at a
rate of 214 beats/minute without visible P
waves.

20. 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

21. SVTSVT
• 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

22. 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

23. SVT - Treatment
• Synchronized cardioversion
• Amiodarone, Procainamide if above
unsuccessful.
• Transesophageal atrial pacing can
also be performed

24. 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

25. 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

26. 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.

27. Ventricular tachycardiaVentricular 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

28. V-Tach
 Treatment: IV lidocaine, procainamide,
amiodarone.
- If critically ill: synchronized cardioversion
- Long term: meds, ablation, or defibrillator

29. 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

30. V-fib
• Brugada syndrome – inherited
arrhythmia, autosomal dominant person
goes into v-fib, faints, dies suddenly.
Treatment: defibrillator, careful screening