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Let's take a closer look at tachycardia for the pediatric patient. An infant's or child's heart rate that is greater than normal for their age, activity level, and clinical condition is considered tachycardia. Now, many things can cause tachycardia, semi-benign things like a fever or stress, or more serious causes like shock and medications, metabolic dysfunction, hypoxemia and damage to the heart muscle, can all cause pediatric tachycardia. Perfusion problems may develop when the heart beats too fast and the ventricles are not able to fill properly with blood. This can cause a decrease in cardiac output, and poor perfusion, and that leads to hemodynamic instability. The faster the heart rate, the more likely the tachycardia is the cause of the patient's symptoms. A thorough primary and secondary survey will help us properly assess the patient's underlying condition. Important steps in caring for an infant or child with tachycardia are to treat the underlying causes first. Our first goal is to make sure we first maintain a patent airway and provide adequate oxygenation. The goal is to maintain an oxygen saturation of at least 94%. Next, we should get a cardiac monitor attached to correctly evaluate what that underlying rhythm is, and if we can, we're going to obtain a 12 lead ECG, but let's be sure not to delay treatment in order to get that 12 lead. There are some helpful signs that can help us identify the type of tachycardia seen on the ECG. First, we want to determine whether the QRS is wide or narrow. A normal or narrow QRS for a pediatric patient is 0.09 seconds or less. Narrow-complex tachycardias typically originate above the ventricles. In contrast, wide-complex tachycardias typically originate in the ventricles, and have a higher risk of deteriorating into full cardiac arrest. Now before I distinguish the different rates for SVT versus sinus tach, I really want to simply state that the major difference between the two is that a sinus tach, though difficult to see on an ECG, will have a P wave. Supraventricular tachycardia does not, in my experience, and therefore SVT is more unstable, and the rate with sinus tach can sometimes be changed with activity. All of that being said, if the patient has a normal QRS we still need to determine whether the patient has sinus tachycardia or supraventricular tachycardia. Sinus tach for an infant is usually a heart rate less than 220 beats per minute, and in a child the heart rate is usually less than 180 beats per minute. The patient's history is usually consistent with the cause of the tachycardia. P waves are present and normal, and the QRS is normal. Heart rate varies with the level of activity. Typically the sinus tachycardia does not require treatment, rather it is important to search for and treat the cause. Now with SVT, for an infant, typically they are going to have a heart rate greater than 220 beats per minute and in a child the heart rate is usually greater than 180 beats per minute. The QRS is normal but the P waves are usually absent. The patient history usually reveals an abrupt change in the heart rate, or may be ambiguous as to what caused the change. The heart rate does not vary with the level of activity. And for treatment of a patient with a regular narrow-complex stable tachycardia it would be appropriate to attempt vagal maneuvers first. For a child, have them attempt to blow through a narrow straw, and for an infant you could place a bag with ice water over the upper half of the infant's face, making sure not to obstruct the airway. If these vagal maneuvers do not work, we may want to consider Adenosine 0.1 milligram per kilogram rapid IV push and it should also be followed with a 20 cc bolus of normal saline in order to expedite the delivery of the medication. If the patient does not convert and remains stable, a second dose of Adenosine may be given at 0.2 milligrams per kilogram rapid IV push. Again, we're going to want to chase that treatment with 20 ccs of normal saline. For a stable patient with an ECG rhythm that shows an irregular narrow-complex QRS tachycardia, though quite unusual, it may likely be atrial fibrillation, atrial flutter, or multi-focal atrial tachycardia. This may require expert consultation for proper treatment. For a stable patient that has regular or irregular wide-complex QRS tachycardia, it would be wise to seek expert consultation as well. Often antiarrhythmics are used to treat this, such as procainamide or amiodarone. However, the management and treatment of wide-complex stable tachycardias requires advanced knowledge of ECG rhythm interpretation and antiarrhythmic therapy. If a child is experiencing SVT or wide-complex tachycardia and remains stable, and does not respond to the medication therapy, we should consult a pediatric cardiologist before we proceed with synchronized cardioversion. For a child with unstable tachycardia, such as a child with hypotension, synchronized cardioversion would be the appropriate first choice. Sedation, if needed, or time allows, would be appropriate, but we don't want to delay cardioversion that is required to stabilize the patient. We're going to start with an energy dose of 0.5 to 1 joule per kilogram. If the initial dose is ineffective, increase that electrical dose to 2 joules per kilogram. Make sure to record and monitor the ECG before, during and after each cardioversion attempt, and it's important to ensure that the defibrillator is set to cardioversion not defibrillation. After cardioversion has been successful, we're going to want to obtain a 12 lead ECG and be sure to pass this patient on to the appropriate next stage of treatment.
In this lesson, we're going to cover tachycardia, including some things to be aware of when dealing with tachycardic pediatric patients, types of tachycardia, underlying causes, and some information on the best courses of treatment to resolve that patient's tachycardia.
When an infant or child's heart rate is greater than normal for their age, activity level, and clinical condition, that patient is considered tachycardic.
Common types of tachycardia include:
Many things can cause tachycardia, including semi-benign causes such as fever or stress. More serious causes of tachycardia include:
Perfusion problems may develop when the patient's heart beats too fast and the ventricles are not able to fill properly with blood. This can cause a decrease in cardiac output and poor perfusion, which can lead to hemodynamic instability.
Pro Tip #1: The faster the heart rate, the more likely it is that the tachycardia is the cause of the patient's symptoms. However, a thorough primary and secondary survey of the patient will help you properly assess any underlying conditions.
It's important to treat the underlying cause first when dealing with a tachycardic pediatric patient. Important steps in caring for an infant or child with tachycardia are:
However, as stated in the last lesson, do not delay treatment while trying to obtain a 12-lead.
There are some helpful signs to aid you in identifying the type of tachycardia seen on the ECG.
First, determine if the QRS is wide or narrow. A narrow/normal QRS for pediatric patients is 0.9 seconds or less.
Pro Tip #2: Narrow complex tachycardias typically originate above the ventricles. By contrast, wide complex tachycardias typically originate in the ventricles and have a higher risk of deteriorating into full cardiac arrest.
Before we distinguish the different rates for SVT vs. sinus tachycardia, it's important to note that the main difference between the two is that sinus tachycardia (though difficult to see on an ECG) will have P-waves, while SVT does not.
Therefore, SVT is more unstable and the rate with sinus tachycardia can sometimes change with activity. Having said that, if the patient has a normal QRS, you'll still need to determine whether that patient has sinus tachycardia or SVT.
Sinus tachycardia for an infant is usually a heart rate of less than 220 beats per minute. While sinus tachycardia for a child is typically a heart rate of less than 180 beats per minute.
It's important to note that a patient's history will usually be consistent with the cause of their tachycardia.
With sinus tachycardia, P-waves are present and normal and the QRS is also normal. And the heart rate will vary with the patient's level of activity.
Usually, sinus tachycardia does not require treatment. Instead, it's important to search for, and treat for, the cause of the tachycardia.
SVT for an infant is usually a heart rate of greater than 220 beats per minute. While sinus tachycardia for a child is typically a heart rate of greater than 180 beats per minute.
With SVT, QRS is normal but P-waves are usually absent. Patient history will usually reveal an abrupt change in heart rate. Alternatively, it can also be ambiguous as to what caused the change. And heart rate does not vary with the level of activity.
Regarding treatment for patients with regular narrow complex stable tachycardia, it's appropriate to first attempt vagal maneuvers. With children, have them attempt to blow through a narrow straw. With infants, place a bag of ice over the upper half of their face, making certain to not obstruct the airway.
If vagal maneuvers don't work, it may be time to consider medications, specifically adenosine at .1mg/kg via rapid IV push, followed with a 20cc bolus of normal saline to expediate the medication delivery.
If the patient doesn't convert and remains stable, a second dose can be given at .2mg/kg, again via rapid IV push, and again, chase the treatment with a 20cc bolus of normal saline.
For stable patients with an ECG rhythm that shows irregular narrow complex QRS tachycardia – while unusual – could be atrial fibrillation, atrial flutter, or multi-focal atrial tachycardia.
Pro Tip #3: The situation above may require expert consultation for proper treatment. For stable patients with regular or irregular wide complex QRS tachycardia, it's wise to seek expert consultation as well.
Often, antiarrhythmics are used to treat wide complex stable tachycardias, such as procainamide or amiodarone. However, the management and treatment of wide complex stable tachycardias requires advanced knowledge of ECG rhythm interpretation and antiarrhythmic therapy.
If a child is experiencing SVT or wide complex tachycardia and remains stable and doesn't respond to medication therapy, consult with a pediatric cardiologist before proceeding with synchronized cardioversion.
For a child with unstable tachycardia, such as a child with hypotension, synchronized cardioversion would be the appropriate first choice. Sedation, if needed and if time allows, would also be appropriate. But don't delay cardioversion that's required to stabilize a patient.
For a child with unstable tachycardia, start with an energy dose of .5 to 1 joules/kg. If the initial dose is ineffective, increase the electrical dose to 2 joules/kg.
Warning: Make certain that the defibrillator is set to cardioversion and not defibrillation.
Make sure to record and monitor the ECG before, during, and after each cardioversion attempt. And after cardioversion has been successful, obtain a 12-lead ECG, then pass this patient on to the appropriate next stage of treatment.