Evaluation & Management of a Child with Arrhythmias

By Dr.Saima Bashir
Post Graduate Trainee Pediatric medicine unit-I Mayo Hospital Lahore

Definition

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.

Classification Of Arrhythmias
Tachycardia
Sinus tachycardia SVT Vent. Fib Vent. Tachy Atril fib. Atrial flutter

Bradycardia
Sinus bradycardia Heart block

Irregular
Sinus arrhythmia PAC PVC

Causes Of Arrhythmias
Congenital
In structurally normal/ abnormal heart Congenital metabolic disorders of mitochondria SLE

Acquired
Rheumatic fever Myocarditis Toxin (diphtheria) Pro-arrhythmic or antiarrhythmic drugs Surgical correction of CHD

Why Basic Understandning Of Arrhytmias Is Important???

Major risk of an arrhythmia is either severe bradycardia or tachycadia dec. cardiac output degeneration into more severe arrhythmias (vent. fib.) To be aware of arrhythmias that occur in otherwise healthy children

Symptoms
Range from
Completely asymptomatic Loss of consciousness Sudden cardiac death

In infants
Lethargy Poor feeding Irritability Cardiac failure Underlying congenital heart disease

In children
Palpitation Syncope Dizziness Chronic fatigue Shortness of breath Chest discomfort

Examination
GPE
Pulse__ irregular, feeble, inc./dec. rate, absent Tachypnea B.P __ Normal, hypotension JVP __ raised in CCF Cyanosis Pallor

CVS
Precordial bulge Right ventricular heave Gallop Murmur

Respiratory system
Bil. Crepts (pulm. edema)

GIT
Hepatomegaly

CNS
Normal Hpotonia

Evaluation Of The Child With An Arrhythmia

History
Symptoms Frequency and length of episode Onset and triggers Any underlying disease Medications
Triggering factor Used for underlying cardiac disease

Evaluation Of The Child With An Arrhythmia

Physical examination
ABCs Hemodynamic stability

Adjunctive testing
12-Lead ECG Holter External event recorders Exercise testing

Evaluation Of The Child With An Arrhythmia

Patient with arrhythmia Ensure ABCs Assess rhythm Absent V FIB Pulseless V Tach PEA

Asysto le

Absen t

Assess pulse
Presen t Fas t Wide QRS V TACH V FIB Narrow QRS Sinus Tachycardia SVT ( PAT ) Atrial flutter Irregu lar Sinus arrhythmia Atrial FIB PAC +/Block PVC

Slow Sinus Bradycardia AVN Block Sick Sinus

Evaluation Of The Child With An Arrhythmia

Assess Pulse
Fast Irregular Slow

P- Wave PR-Interval

Normal

Prolonged PR-Interval

Sinus Bradycardia

Heart- block

Evaluation Of The Child With An Arrhythmia

Assess Pulse
Fast Irregular Slow

P- Wave QRS- Complex

Normal but different shape QRS complex complex Normal P- Wave ) Wide QRSFibrillatory(Multiple Normal QRS- ComplexP- Wave Present Sinus Arrythmia

PVC

Atrial Fib.

PAC

Evaluation Of The Child With An Arrhythmia

Assess Pulse
Fast QRS- Complex QS Wide P- Wave QRS Normal P- Wave Irregular Slow

Absent or Atriovent dissociation Present No P- Wave low amplitude QRS- Complex Sinus trachycardia V- Tech

Absent

Sawtooth Appearance

SVT Atrial flutter V- Fib.

Pediatric Dysrhythmias
Treatment not required
Sinus arrhythmia

Treatment is required
Supraventricular tachycardia

Wandering atrial pacemaker Sinus tachycardia Isolated premature atrial contractions Isolated premature ventricular contractions First degree AV block Sinus bradycardia Ventricular tachycardia Third degree AV block with symptoms

Reproduced from Zitellis Atlas of Pediatric physical diagnosis, 2007, pg 140.

Sinus Rhythm
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). The P wave morphology and axis must be normal and PR interval will usually be normal for that age

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 expiration

Sinus Arrhythmia

Normal phasic variation of heart rate with respiration Variable P-P intervals No treatment needed

Wandering Atrial Pacemaker

normal QRS complex Change in P-wave configuration

Wandering Atrial Pacemaker

Atrial pacemaker shifts intermittently from sinus node to another atrial site Normal variant May also be seen in CNS disturbances like subarachnoid hemorrhage

Premature Atrial Contraction

Ectopic focus in atria or AV node Narrow but normal QRS Normal P wave

Isolated PACs
Premature atrial contractions Benign in absence of underlying heart disease 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 PVCs)

Premature Ventricular Contraction

Ectopic beat activates ventricle before the wave of depolarization from normal sinus node Abnormally wide QRS complex appears early which are not preceded by P-wave T-wave points in the direction opposite to QRS complex

Bigeminy, trigeminy, couplet Unifocal, multifocal Three or more successive PVCs are termed as ventricular tachycardia

Premature Ventricular Contraction

Not very commonly seen in children Incidence of 0.3 to 2.2 % Myocarditis cardiomyopathy myocardial injury CHD long QT syndrome hypokalemia hypomagnesemia Hypoxia Drugs: Digitalis toxicity, catecholamines, theophylline, caffeine, anesthetics, Class I and III anti-arrhythmics

PVCs

unifocal, disappear with exercise, and associated with structurally and functionally normal heart, then considered benign, no therapy needed

PVCs Evaluation

Indicated if Two or more PVCs in a row Multifocal origin Increased vent. Ectopic activity with exercise R on T phenomenon (PVC occurs on preceding beat) Presence of underlying heart disease

PVCs Evaluation
12 lead EKG, Echocardiogram Perhaps Holter monitoring Brief exercise in office to see if ectopy suppressed or more frequent Treatment:
Correction of underlying condition IV lignocaine 1st line drug Amiodarone in refractory cases with hemodyanamic compromise

Evaluation Of The Child With An Arrhythmia

Assess Pulse
Fast Irregular Slow

P- Wave PR-Interval

Normal

Prolonged PR-Interval

Sinus Bradycardia

Heart- block

Sinus Bradycardia

Normal P wave axis and P-R interval HR < 5th percentile for age

Sinus Bradycardia
Athletic individuals (normal) Increased ICP hypoxia hyperkalemia hypercalcemia vagal stimulation hypothyroidism hypothermia long QT syndrome Drugs: digoxin, beta-blockers, clonidine, opiods, sedative-hypnotics, amiodarone Treatment: address underlying cause

Long Q-T Syndrome

Bradycardia

Prolonged QT interva Notched T- wave

Long Q-T Syndrome

Genetic abnormality of vent. Repolarization 50% cases familial Romano Ward syndrome common form of LQTS Drugs causing LQTS: terfenadine, cisapride, droperidol Clinical manifestation:
Syncope induced by exercise, fright, startle Some events occur during sleep Seizures Palpitation Cardiac arrest (10%)

Long Q-T Syndrome

Diagnostic criteria:
QTc >0.47 __ indicative QTc >0.44 __ suggestive Notched T- wave Low heart rate for age Syncope Family H/O LQTS or unexplained sudden death 12 lead ECG Holter Monitoring Exercise testing

Investigation

Long Q-T Syndrome

Treatment:
Beta blockers __ to blunt heart response to exercise Pacemaker if drug induces profound bradycardia Implanted cardiac defibrillators
Continuous syncope No response to drug treatment Experienced cardiac arrest

Sick Sinus Syndrome

Result of abnormality in sinus node or atrial conduction pathway or both Arrhythmias include sinus bradycardia, blocks, sinus arrest with junctional escape, paroxysmal atrial tachycadia. Most common after surgical correction of CHD Clinical manifestations depend on heart rate
Asymptomatic Dizziness Syncope

Treatment: pacemaker therapy in symptomatic patient

Alogrithm For Pediatric Bradycardia

Assess and supports ABCs Provide 100% oxygen Attach monitor Vascular Access

No
Observe Support ABCs Consider tranfer or transport to ALS facility

Yes

Is bradycardia causing severe cardiorespiratoy compromist?? Poor perfusion, hypotension, respiratory difficulty. Altered conciousness

Perform chest compression If despite oxygenation and ventilation HR <60/min in infant or child and poor systemic perfusion

Give atropine 1st for bradycardia due to suspected increase vagal tone or primary AV block

During CPR Attempt / verify Endotracheal intubation and vascular access Check Electrode position and contact Paddle position and contact Give Epinephrine every 3 to 5 min( consider high doses for for second and subsequent doses) epinephrine or dopamine infusion Identify and treat causes Hypoxemia Hypothermia Heart block Heart transplant Toxins/poisons/drugs

Epinephrine lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg) Endotrachealtube: 0.1mg/kg (1:10,000; 0.1 ml/kg) May repeat every 3-5 min. at same dose

Atropine: 0.02mg/kg (min.dose 0.1mg) May be repeated once

Consider cardiac pacing

If pulseless arrest develops see pediatrics pulseless arrest algorithm

Alogrithm For Pediatric Bradycardia Assess and supports ABCs Assess and supports ABCs Provide 100% oxygen Provide 100% oxygen Attach monitor Attach monitor Vascular Access Vascular Access Is bradycardia causing severe Yes No cardiorespiratoy compromist?? Is bradycardia causing severe cardiorespiratoy compromist?? (Poor perfusion, hypotension, respiratory Perform chest compression Observe Poor perfusion, hypotension, respiratory Observe difficulty. Altered conciousness ) Support ABCs Perform chest compression difficulty. Altered conciousness If despite oxygenation and Support ABCs or Consider tranfer If despite oxygenation and During CPR ventilation transport to ALS or ventilation Consider tranfer facility Attempt / verify HR <60/min in infant or child and HR <60/min in infant or child and transport to ALS poor systemic perfusion Endotracheal intubation and vascular poor systemic perfusion facility access During CPR Epinephrine Epinephrine Check Attempt / verify lV/lO : 0.01mg/kg (1:10,000; lV/lO : 0.01mg/kg (1:10,000; Endotracheal intubation contact Electrode position andand vascular 0.1 access 0.1 ml/kg) ml/kg) Paddle position and contact Endotrachealtube: 0.1mg/kg Check Endotrachealtube:ml/kg) (1:10,000; 0.1 0.1mg/kg Electrode position and contact Give May 0.1 every 3-5 (1:10,000; repeatml/kg) min. at Paddle position and contact Epinephrine every 3 to 5 same dose Give May repeat every 3-5 min. at Epinephrine every 3 to 5 min( consider min( consider high doses for for same dose high doses for for second and second subsequent doses) epinephrine or and subsequent doses) Atropine: 0.02mg/kg Atropine: 0.02mg/kg st for epinephrine or infusion dopamine dopamine infusion (min.dose 0.1mg) Give atropine 1 (min.dose 0.1mg) bradycardia due to IdentifyIdentifytreat causes and and treat causes May be repeated once st for May be repeated once Give atropine 1 Hypoxemia suspected increase Hypoxemia bradycardia due to Hypothermia suspected or primary Heart block vagal tone increase Hypothermia vagal tone or primary Consider cardiac pacing Heart Consider cardiac pacing AV AV block block Heart block transplant Toxins/poisons/drugs Heart transplant If pulseless arrest develops If pulseless arrest develops Toxins/poisons/drugs see pediatrics pulseless arrest
see pediatrics pulseless arrest algorithm algorithm

AV Nodal Block First- Degree Heart Block

Delayed conduction through AV node Prolongation of PR interval

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 msecin young children and adults

Generally does not cause bradycardia since AV conduction remains intact

AV Nodal Block First-Degree Heart Block

Usually asymptomatic Diseases that can be associated with first degree AV block:

Acute rheumatic fever Lyme disease, CHD (ASD, Ebsteins anomaly), cardiomyopathy, post-cardiac surgery, normal children Hypothermia Electrolyte disturbances

AV Nodal Block First-Degree Heart Block

Drugs: Digitalis toxicity Treatment: Address underlying cause Isolated finding- benign, no treatment and no follow up needed

Second-Degree Heart Block: Mobitz Type I - Wenckebach

P

Progressive lengthening of PR interval until a QRS is not conducted (ventricular contraction does not occur)

Second-Degree Heart Block: Mobitz Type I - Wenckebach

Does not usually progress to complete heart block Diseases that can be associated

Myocarditis, cardiomyopathy, CHD, cardiac surgery, MI, normal children at times of increased
parasympathetic activity

Drugs: digitalis toxicity, beta-blocker toxicity Treatment: address underlying cause

Second-Degree Heart Block: Mobitz Type Il

Constant PR interval before a skipped ventricular conduction

Second-Degree Heart Block: Mobitz Type Il

Block below the AV node in the bundle of His Not found in normal children, usually those with structural disease or post-op May progress to complete heart block May require pacemaker

Third-Degree Heart Block: Complete

Complete dissociation of atrial and ventricular conduction P wave and PR interval normal Junctional pacemaker narrow QRS Ventricular pacemaker wide QRS Rate 30 50 beats/min

Third-Degree Heart Block: Complete

Congenital: maternal lupus or CT disease, CHD (L-TGA or abnormal AV septum) Acquired: post-op, acute rheumatic fever, Lyme carditis, myocarditis, cardiomyopathy, MI 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

Sinus Tachycardia

Normal sinus rhythm age HR >95th percentile for Usually < 230 beats/min

Sinus Tachycardia
Hypovolemia Anemia shock fever Sepsis CHF anxiety Drugs: Beta-agonists, aminophylline, atropine Treatment: address underlying cause.

Supraventricular Tachycardia

> 230 beats/min Narrow QRS P waves not visible

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

Causes:
Idiopathic CHD (Ebsteins anomaly, transposition)

SVT - Presentation
Paroxysmal, sudden onset & offset Rates of SVT vary with age Overall average rate for all ages: 235 bpm P waves difficult to define, but 1:1 with QRS Important to differentiate from sinus tachycardia

SVT - Presentation
Older kids can describe a sensation of a fast heart rate, palpitations, or chest tightness Hemodynamic compromise (CCF) in newborns and those with structural heart disease

SVT -Treatment
Goal: identify unstable patients, differentiate from sinus tachycardia, and terminate the rhythm

Alogrithm For Pediatric Tachycardia With Adequate Perfusion

Assess and supports ABCs (assess signs of circulation and pulse) Provide oxygen and ventilation as needed Attach monitor Evaluate 12 lead ECG if pratical

Evaluate Rhythm

0.08 sec

What is QRS Duration?

> 0.08
sec

Probable ventricular tachycardia Consider alternative Medication Lidocane 1mg/ kg IV bolus (wide complex only)

Probable sinus tachycardia

History compatible P-wave present/Normal HR often varies with activity Variable RR with constant PR Infant : rate usually <220 bpm Children: rate usually <180 bpm

Probable supraventicular tachycardia History incompatible P-wave absent/ abnormal HR not variable with activity Abrupt rate changes Infant : rate usually >220 bpm Children: rate usually >180 bpm

Consider Vagal Maneuvers (no delay) Establish vascular access

Consider adenosine 0.1mg/ kg lV/ lO (maximum first dose of 6 mg) May double and repeat dose once (maximum 2nd dose of 12 mg) Techniques: use rapid bolus technique

During evaluation
Provide oxygen and ventilation as needed Conform continuous monitor Medical control consultation Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg

Identify and treat possible causes

Hypoxemia tamponade Hypovolemia tension pneumothorax Hyperthemia posion/ toxin / drugs Hyper-/ hypokalemia thromoembolism

Any further out of hospital interventions require medical control Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg

Alogrithm For Pediatric Tachycardia With Adequate Perfusion Assess and supports ABCs (assess signs of circulation Assess ABCs (assess signs and pulse) and supportsventilation as needed of circulation and pulse) Provide oxygen and Attach oxygen Provide monitor and ventilation as needed Evaluate 12 lead Attach monitor ECG if pratical Evaluate 12 lead ECG if pratical> 0.08 sec 0.08 sec Probable ventricular EvaluateRhythm Evaluate Rhythm What is QRS Duration? What is QRS Duration? tachycardia
Probable sinus tachycardia
History incompatible Medication History incompatible History compatible P-wave absent/ abnormal Lidocane 1mg/ kg IV bolus P-wave present/Normal P-wave absent/ abnormal HR not variable with activity (wide complex only) HR often varies with activity Abrupt rate changes HR not variable with activity Variable RR with constant PR Infant Provide oxygen and ventilation as needed : rate usually >220 bpm Infant : rate usually <220 Abrupt rate changes bpm Children: rate usually >180 bpm Conform continuous monitor Children: rate usually <180 bpm

Probable supraventicular tachycardia Probable supraventicular tachycardia Consider alternative During evaluation

Establish vascular access

Infant : rate usually >220 bpm Medical control Children: rate usually >180 bpmconsultation During evaluationcardio version (consider sedation) Prepare for Consider Vagal Maneuvers Consider Vagal Maneuvers Provide oxygen 0.5 to 1.0 j/kg and ventilation as needed (no delay) (no delay) Conform continuous monitor

Medical control consultation lO Establish vascular access Consider adenosine 0.1mg/ Identify and treat version (consider sedation) 0.5 to 1.0 j/kg kg lV/Prepare for cardio possible causes Consider adenosine 0.1mg/ kg lV/ Tamponade (maximum first dose of 6 mg) 6 mg) Hypoxemia treat possible causes Identify and lO (maximum first dose of Hypoxemia Tamponade Hypovolemia May double and repeat dose once dose once (maximum Tension pneumothorax May double and repeat nd dose of 12 mg) Hypovolemia Tension pneumothorax (maximum 2 Hyperthemia Posion/ drugs 2ndTechniques: use rapid bolus dose of 12 mg) Hyperthemia Posion/ toxin / toxin / drugs Hyper-/ hypokalemia Thromoembolism technique Techniques: use rapid bolusHyper-/ hypokalemia Thromoembolism technique

Any further out of hospital interventions require medical control

Any further out of hospital interventions require medical control

Consult for possible sedation & cardio version orders to 1.0to 1.0 j/kg 0.5 j/kg Consult for possible sedation & cardio version orders 0.5

Alogrithm For Pediatric Tachycardia With Poor Perfusion

Assess and supports ABCs Initial CPR See pulseless alogrithm NO
Pulse Present?

YES
Provide oxygen or ventilation as needed Attach monitor 12 lead ECG if practical Evaluate QRS duration Probable supraventicular tachycardia History incompatible P-wave absent/ abnormal HR not variable with activity Abrupt rate changes Infant : rate usually >220 bpm Children: rate usually >180 bpm

QRS duration normal for age(app. < 0.08 sec) Evaluate the tachycardia
Probable sinus tachycardia History compatible P-wave present/Normal HR often varies with activity Variable RR with constant PR Infant : rate usually <220 bpm Children: rate usually <180 bpm

QRS duration normal for age(app. > 0.08 sec) Evaluate the tachycardia Probable venticular Tachycardia Immediate Cardioversion 0.5 to 1.0 j/kg (consider sedation do not delay cardioversion)
Consider alternative Medication Lidocane 1mg/ kg IV bolus (wide complex only)

Consider Vagal Maneuvers (no delay)

Immediate cardioversion Attempt cardioversion with 0.5 to 1.0j/kg (may increase to 2j/kg if initial dose is ineffective) Use sedation if possible Sedation must not delay cardioversion
OR Immediatie lV/lO adenosine

Adenosine: use if lV access immediately available Dose: Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg) May double and repeat dose once (max 2nd dose of 12 mg) Technique: use rapid bolus technique During evaluation Provide oxygen and ventilation as needed Conform continuous monitor Medical control consultation Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg Identify and treat possible causes Hypoxemia tamponade Hypovolemia tension pneumothorax Hyperthemia posion/ toxin / drugs Hyper-/ hypokalemia thromoembolism

Alogrithm For Pediatric Tachycardia With Poor Perfusion

Assess and supports ABCs
Assess and supports ABCs Initial CPR See pulseless alogrithm NO

Pulse Present? Pulse Present?

YES QRS duration normal for age(app.

dose is ineffective) Immediate cardioversion Use sedation if possible Consider Vagal Attempt cardioversion with 0.5 to 1.0j/kg (may increase to 2j/kg if initial dose is ineffective) Consider Use sedation possible Vagal must Maneuvers Sedationmustif not not delay cardioversion Sedation Maneuvers delay cardioversion (nodelay) OROR (no delay) Immediatie ImmediatielV/lO adenosine lV/lO adenosine Adenosine: use if lV access immediately available During evaluation Identify and treat Adenosine: use if lV access immediately available possible causes Dose: Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg) Provide oxygen and ventilation0.1mg/kg lV/lOdose of 12 st dose of 6 mg) Hypoxemia Tamponade May double and repeat as once (max Dose: Adenosine doseneeded 2nd (max 1 mg) Technique: use rapid Conform continuous monitor repeat dose once Hypovolemia of 12 mg) pneumothorax May double and bolus technique (max 2nd dose Tension During evaluation Identify Medical control consultation rapid bolus technique and treat possible causes Hyperthemia Posion/ toxin / drugs Technique: use Provide oxygen and ventilation as needed Hypoxemia tamponade Prepare for cardio monitor (consider version Hyper-/ hypokalemia pneumothorax Thromoembolism Conform continuous Hypovolemia tension sedation) 0.5 to 1.0 j/kg Medical control consultation Hyperthemia posion/ toxin / drugs
Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg Hyper-/ hypokalemia thromoembolism

Provide oxygen or or ventilation as as needed > 0.08 sec) Provide oxygen ventilation needed Attach monitor QRS duration normal for age(app. Attach monitor Evaluate the tachycardia < 0.08 sec) 12 lead ECG if practical 12 lead ECG if practical Evaluate the tachycardia Evaluate the tachycardia Evaluate QRS duration Evaluate QRS duration Probable supraventicular tachycardiaProbable venticular Tachycardia Immediate Cardioversion Probable supraventicular History incompatible tachycardia Probable sinus tachycardia 0.5 to 1.0 j/kg (consider sedation History incompatible History compatible P-wave absent/ abnormal do not delay cardioversion) P-wave absent/ abnormal P-wave present/Normal HR not variable with activity HR not variable withactivity HR often varies with activity Abrupt rate changes Variable RR with constant PR Abrupt rate changes Consider alternative Medication Infant : rate usually >220 bpm Infant : rate usually <220 bpm Lidocane 1mg/ kg IV bolus (wide Children: rate usually >180 bpm Children: rate usually <180 cardioversion usually >220bpm Immediate Infant : rate complex only) bpm Children: with 0.5 to 1.0j/kg bpm increase to 2j/kg if initial rate usually >180 (may Attempt cardioversion

SVT -Treatment
Need post conversion EKG identify those with WPW syndrome ( 25 % pts with SVT) Will also need an echo identify structural problems Medications (to prevent recurrance)

Digoxin and beta blockers as first line Flecainide, sotalol, amiodarone

Observation and expectant management Radiofrequency catheter ablation

Frontline treatment Very effective Cutoff points usually are 5 y.o. and 15 kg, unless severe
SVT

Supraventricular Tachycardia WPW

Accessory pathway establishes cyclic pattern of signal reentry Impulse arrives at ventricle rapidly without delay at the AV node Independent of AV node Most common cause of nonsinus tachycardia in children

Wolff-Parkinson-White Syndrome

Delta wave vslurred upstroke of QRS vReflects pre-excitation Short PR- interval Wide QRS complex

Atrial Flutter

Atrial rate 250-350 beats/min Sawtooth (no discrete P waves) Normal QRS complex

Dilated Atria, intraatrial surgery Digitalis toxicity Post-Fontan procedure patients

Atrial Flutter

Management
Emergency:
Vagal maneuver adenosine

Chronic atrial flutter:

Inc. risk of thromboembolism and stroke Anticoagulation Radiofrequency ablation in CHD in older child

Synchronized cardioversion0.5-2 J/kg Overdrive pacing Long term:

Digoxin+/- B- Blockers Ablation

Atrial Fibrillation

Atrial rate 350-600 beats/min Atrial waves are totally irregular P wave vary in size and shape from beat to beat vent. response is irregularly irregular QRS complexes are usually normal

Atrial Fibrillation
Much less common Chronically stretched atria
Intra atrial surgery Left atrial enlargement due to mitral valve insufficiency WPW syndrome Thyrotoxicosis Pulm. Embolism Pericarditis familial

Atrial Fibrillation
Treatment:
Restore normal heart rate by digitalization (avoided in WPW syndrome) Restore normal rhythm by adding quinidine/procainamide/DC cardioversion Prevention of thromboembolic phenomenon and stoke by warfarin

Ventricular Tachycardia

120-150 beats/min Wide QRS 3 or more consecutive beats from the ventricle (PVCs)

85% have abnormal cardiac anatomy Metabolic abnormalities Drugs/toxins: tricyclic antidepressants

V-Tach
Associated with
Myocarditis Anomalous origin of coron. A. Rt. Vent. Dysplasia Mitral valve prolapse CMP LQTS WPW synd. Drugs(cocaine, amphetamine)

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

Alogrithm For Pediatric Tachycardia With Adequate Perfusion

Assess and supports ABCs (assess signs of circulation and pulse) Provide oxygen and ventilation as needed Attach monitor Evaluate 12 lead ECG if practical 0.08 sec 0.08 sec

Evaluate Rhythm

What is QRS Duration?

Probable ventricular tachycardia

Consider alternative Medication Lidocane 1mg/ kg IV bolus (wide complex only)

Probable sinus tachycardia

History compatible P-wave present/Normal HR often varies with activity Variable RR with constant PR Infant : rate usually <220 bpm Children: rate usually <180 bpm

Probable supraventicular tachycardia History incompatible P-wave absent/ abnormal HR not variable with activity Abrupt rate changes Infant : rate usually >220 bpm Children: rate usually >180 bpm

Consider Vagal Maneuvers (no delay) Establish vascular access

Consider adenosine 0.1mg/ kg lV/ lO (maximum first dose of 6 mg) May double and repeat dose once (maximum 2nd dose of 12 mg) Techniques: use rapid bolus technique

During evaluation
Provide oxygen and ventilation as needed Conform continuous monitor Medical control consultation Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg

Identify and treat possible causes

Hypoxemia tamponade Hypovolemia tension pneumothorax Hyperthemia posion/ toxin / drugs Hyper-/ hypokalemia thromoembolism

Any further out of hospital interventions require medical control Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg

Alogrithm For Pediatric Tachycardia With Adequate Perfusion

Assess and supports ABCs (assess signs of circulation Assess and supports ABCs (assess signs of circulation and pulse) pulse) Provide Provide oxygen and ventilation as needed needed oxygen and ventilation as Attach monitor Attach monitor ECG if practical Evaluate 12 lead Evaluate 12 lead ECG if pratical
0.08 sec

and

Evaluate Rhythm

What is is QRSDuration? What QRS Duration?

0.08 sec

Probable ventricular Probable ventricular tachycardia tachycardia

Probable sinus tachycardia

History compatible P-wave present/Normal HR often varies with activity Variable RR with constant PR Infant : rate usually <220 bpm Children: rate usually <180 bpm

Probable supraventicular tachycardia Lidocane 1mg/ kg IV bolus Consider alternative History incompatible (wide Medication1mg/ kg IV bolus complex only) Lidocane P-wave absent/ abnormal Consider alternative (wide complex only) HR not variable with activity Abrupt rate changes Medication Infant : rate usually >220 bpm During evaluation >180 bpm Children: rate usually

Consider Vagal Maneuvers (no delay) Establish vascular access

Consider adenosine 0.1mg/ kg lV/ lO (maximum first dose of 6 mg) May double and repeat dose once (maximum 2nd dose of 12 mg) Techniques: use rapid bolus technique

Provide oxygen and ventilation as needed Conform continuous monitor During evaluation Medical control consultation Provide oxygen and ventilation as needed Prepare for cardio version (consider sedation) 0.5 to Conform continuous monitor 1.0 j/kgMedical control consultation
Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg

Identify and treat possible causes Identify and treat possible causes Hypoxemia Tamponade Hypoxemia tamponade Hypovolemia tension pneumothorax Tension pneumothorax Hypovolemia Hyperthemia Hyperthemia posion/ toxin / drugs / drugs Posion/ toxin Hyper-/ hypokalemia thromoembolism Hyper-/ hypokalemia Thromoembolism

Any Any further out of hospitalinterventionsrequire medical control further out of hospital interventions require medical control Consult for for possible sedation & cardio version orders 0.5 to 1.0 j/kg j/kg cardio version orders 0.5 to 1.0 Consult possible sedation

Alogrithm For Pediatric Tachycardia With Poor Perfusion

Assess and supports ABCs Initial CPR See pulseless alogrithm NO
Pulse Present?

YES
Provide oxygen or ventilation as needed Attach monitor 12 lead ECG if practical Evaluate QRS duration Probable supraventicular tachycardia History incompatible P-wave absent/ abnormal HR not variable with activity Abrupt rate changes Infant : rate usually >220 bpm Children: rate usually >180 bpm

QRS duration normal for age(app. < 0.08 sec) Evaluate the tachycardia
Probable sinus tachycardia History compatible P-wave present/Normal HR often varies with activity Variable RR with constant PR Infant : rate usually <220 bpm Children: rate usually <180 bpm

QRS duration normal for age(app. > 0.08 sec) Evaluate the tachycardia Probable venticular Tachycardia Immediate Cardioversion 0.5 to 1.0 j/kg (consider sedation do not delay cardioversion)
Consider alternative Medication Lidocane 1mg/ kg IV bolus (wide complex only)

Consider Vagal Maneuvers (no delay)

Immediate cardioversion Attempt cardioversion with 0.5 to 1.0j/kg (may increase to 2j/kg if initial dose is ineffective) Use sedation if possible Sedation must not delay cardioversion
OR Immediate lV/lO adenosine

Adenosine: use if lV access immediately available Dose: Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg) May double and repeat dose once (max 2nd dose of 12 mg) Technique: use rapid bolus technique During evaluation Provide oxygen and ventilation as needed Conform continuous monitor Medical control consultation Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg Identify and treat possible causes Hypoxemia tamponade Hypovolemia tension pneumothorax Hyperthemia posion/ toxin / drugs Hyper-/ hypokalemia thromoembolism

Alogrithm For Pediatric Tachycardia With Poor Perfusion

Assess and supports ABCs Assess and supports ABCs
Initial CPR See pulseless alogrithm NO
Pulse Present? Pulse Present?

YES

Provide oxygen or ventilation as needed > 0.08 sec) Provide oxygen or ventilation as needed Attach monitor QRS duration normal for age(app.

QRS duration normal for age(app.

< 0.08 sec) Evaluate the tachycardia

Probable sinus tachycardia History compatible P-wave present/Normal HR often varies with activity Variable RR with constant PR Infant : rate usually <220 bpm Children: rate usually <180 bpm

Attach monitor 12 ECG if practical 12 lead lead ECG if practical Evaluate QRS duration Evaluate QRS duration

Evaluate tachycardia Evaluate the the tachycardia

Probable venticular Tachycardia Probable venticular Tachycardia Immediate Cardioversion Probable supraventicular tachycardia Immediate Cardioversion 0.5 to 1.0 j/kg (consider sedation History incompatible 0.5 do not delay cardioversion) to 1.0 j/kg (consider P-wave absent/ abnormal HR not variable with activity sedation do not delay Abrupt rate changes cardioversion) alternative Medication Consider Infant : rate usually >220 bpm Consider alternative Medication Lidocane 1mg/ kg IV bolus (wide Children: rate usually >180 bpm Lidocane 1mg/ kg IV bolus (wide complex only) complex only)

Consider Vagal Maneuvers (no delay)

Immediate cardioversion Attempt cardioversion with 0.5 to 1.0j/kg (may increase to 2j/kg if initial dose is ineffective) Use sedation if possible Sedation must not delay cardioversion
OR Immediate lV/lO adenosine

During evaluation Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg) and treat possible causes Identify Dose: May double and repeat dose needed Provide oxygen and ventilation as once (max 2nd Hypoxemia dose of 12 mg) tamponade Technique: use rapid bolus technique Conform continuous monitor Hypovolemia tension pneumothorax During evaluation Identify and treat possible causes Medical control consultation Hyperthemia posion/ toxin / drugs Provide oxygen and ventilation as needed Hypoxemia tamponade Prepare for cardio version (consider Hyper-/ hypokalemia pneumothorax Conform continuous monitor Hypovolemia tension thromoembolism Medical control consultation Hyperthemia posion/ toxin / drugs sedation) 0.5 to 1.0 j/kg
Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kg Hyper-/ hypokalemia thromoembolism

Adenosine: use if lV access immediately available

Ventricular Fibrillation

Rapid and irregular ventricular arrhythmia Low amplitude QRS primary form or from degeneration of unstable SVT

Rare in children MI, post-op, myocarditis, severe hypoxia, long QT syndrome Digitalis and quinidine toxicity, catecholamines

V-fib

Presents with pulse less cardiac arrest Fatal dysrhythmia. Death if untreated/uncorrected Thump on chest may occasionally restore sinus rhythm Treatment: immediate defibrillation, CPR

Alogrithm For Pediatric Pulseless Arrest

Assess and supports ABCs Provide 100% oxygen Attach monitor VF/ VT
Attempt defibrillation Upto 3 times if needed Initially 2 j/kg, 2 to 4 j/kg, 4 j/kg Access rhythm ECG PEA/ Aystole

Epinephrine lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg) Endotrachealtube: 0.1mg/kg (1:10,000; 0.1 ml/kg)

Attempt defibrillation with 4J/kg within 30 to 60 sec after each medication Pattern should be CPR-drugshock (repeat) ore CPR-drugshock-shock-shock (repeat)

Antiarrythmic Lidocane: 1mg/kg bolus / lV/lO/ET Attempt defibrillation with 4J/kg within 30 to 60 sec after each medication Pattern should be CPR-drugshock (repeat) ore CPR-drugshock-shock-shock (repeat)

During CPR Attempt / verify Endotracheal intubation and vascular access Check Electrode position and contact Paddle position and contact Give Epinephrine every 3 to 5 min( consider high doses for for second and subsequent doses) Consider alternative medications Vasopressors Antiarrhythics Bicarbonate Identify and treat causes Hypoxemia Hypovalemia Hypothermia Hyperkalemia/ hypokalemia and metabolic disorders Tamponade Tension pneumothorax Toxins/poisons/drugs Thromoboembolism

Epinephrine lV/lO : 0.01mg/kg (1:10,000; 0.1 ml/kg) Endotrachealtube: 0.1mg/kg (1:10,000; 0.1 ml/kg)

Continue CPR upto 3 min.

Alogrithm For Pediatric Pulseless Arrest Assess and supports ABCs Assess and supports ABCs Provide 100% oxygen Provide 100% oxygen Attach monitor Attach monitor VF/ VT VF/ VT
During CPR Attempt defibrillation Attempt defibrillation Upto 3 times if needed Upto 3 times if needed Attempt / verify Initially 2 j/kg, j/kg, j/kg,Endotracheal intubation and vascular access 4 4 j/kg, Initially 2 2 to 4 2 to j/kg During CPR Check 4 j/kg Attempt / verify
Access rhythm ECG Access rhythm ECG PEA/ Aystole PEA/ Aystole Epinephrine Epinephrine lV/lO : 0.01mg/kg (1:10,000; lV/lO : 0.01mg/kg 0.1 ml/kg) (1:10,000; 0.1 ml/kg) Endotrachealtube: 0.1mg/kg (1:10,000; 0.1 ml/kg) Endotrachealtube:

Electrode position andintubation and vascular Endotracheal contact Epinephrine Epinephrine Paddle position and contact access lV/lO : 0.01mg/kg (1:10,000; 0.1 Check lV/lO : 0.01mg/kg 0.1mg/kg (1:10,000; ml/kg) Give Electrode position and contact Endotrachealtube: 0.1mg/kg (1:10,000; 0.1 ml/kg) ml/kg) Epinephrine every 3 to 5 min(contact consider high doses for Paddle position and (1:10,000; 0.1 ml/kg) Endotrachealtube: second and subsequent doses) Give Epinephrine every 3 to 5 Consider Attempt defibrillation with alternative medicationsmin( consider 0.1mg/kg (1:10,000; 0.1 Attempt defibrillation to 60Vasopressors high doses for for second and with 4J/kg sec 4J/kg within 30 ml/kg) subsequent doses) Continue CPR within 30 to 60 sec after each Continue CPR Antiarrhythics after each medication Consider alternative medications upto 3 min. medication upto 3 min. CPRBicarbonate Vasopressors Pattern should be CPR-drugPattern should be shock (repeat) ore CPR-drugAntiarrhythics Identify drug-shock (repeat) ore and treat causes shock-shock-shock (repeat) Hypoxemia Bicarbonate CPR-drug-shock-shockIdentify and treat causes HypovalemiaHypoxemia shock (repeat) Antiarrythmic Antiarrythmic Lidocane: 1mg/kg bolus / HypothermiaHypovalemia Attempt defibrillation with/ Lidocane: 1mg/kg bolus Hypothermia Hyperkalemia/ hypokalemia and metabolic disorders lV/lO/ET lV/lO/ET 4J/kg within 30 to 60Tamponade Hyperkalemia/ hypokalemia and sec metabolic disorders after each medication Tension pneumothorax Tamponade Attempt defibrillation with 4J/kg Pattern should be CPRTension pneumothorax within 30 to 60 sec after each Toxins/poisons/drugs Toxins/poisons/drugs drug-shock (repeat) or medication Thromoboembolism Thromoboembolism Pattern should be CPR-drugCPR-drug-shock-shockshock (repeat) ore CPR-drugshock (repeat) shock-shock-shock (repeat)

0.1

V-fib
Anti-arrhythmic drugs indicated if defib. Ineffective or fib. recurs After recovery from fib. Search for underlying cause Ablation in WPW syndrome If no correctable abnormality identified, ICD indicated b/c of inc. risk of sudden death

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Curious Minds = Successful Minds

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What is sinus rhythm?

a.When each P-wave is followed by QRS- complex b.When each QRS-complex is preceded by P-wave c.Normal P-wave and PR interval d.All of above

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This is the ECG of a 2yr old girl presented with history of vomiting and fast heart rate a. What two abnormalities are shown up on ECG? b. What is most likely diagnosis? c. Three possible therapeutic procedure?

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a. Tachycardia(Heart rate 214/min) No P-wave b. Supraventricular Tachycardia c. Carotid sinus message Submerge face in cold water or put an ice bag on face lV Adenosine

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This is the ECG of six year old boy referred to the output patient clinic with a heart murmur a. What three abnormalities are shown in ECG b. What is diagnosis? c. Name two complications which may arise?
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a.Short PR interval Wide QRS Delta Waves b.Wolf parkinson-White-Syndrome c. Supraventricular tachycardia Heart block

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a. What is diagnosis? b. What treatment is required in a asymptomatic patient without underlying heart disease if these disappear with exercise?

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a.PVC b.No Treatment

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a.What is diagnosis? b.What is immediate treatment?

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a.Venticular fib. b.Defibrillation

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