Approach to tachyarrthymia

1. APPROACH TO TACHYARRYTHMIA
DR. AKSHAY RAUNDHAL
GUIDE : DR. RACHANA SONTAKKE

2. Physiology

3. Tachycardia
• Heart rate greater than what is considered normal for the child’s age.

4. AGE RANGE
NEWBORN 90-180
6MO 106-185
1 YEAR 105-170
2 YEARS 90-150
4 YEARS 72-135
6 YEARS 65-135
10 YEARS 65-130
14 YEARS 60-120

5. Why Tachycardia is harmful?
• Shortened relaxation phase leads to two main problems
a) Ventricles are unable to fill completely, so cardiac output is
lowered.
b) Coronaries receives less blood supply to heart, so supply to heart is
decreased.

6. Paediatric Tachyarythmias
Divided into
Narrow QRS Complex Wide QRS Complex
Atrial Fibrillation/Flutter Ventricular Tachycardia
Sinus Tachycardia Unusual SVT
Supraventricular Tachycardia

7. Normal ECG

8. CHARACTERISTICS OF SINUS RHYTHM
All rhythms that originate in the sinoatrial (SA) node (sinus rhythm) have two
important characteristics (Fig. 24.1). Both are required for a rhythm to be called
sinus rhythm.
1. P waves precede each QRS complex with a regular PR interval
2. The P axis falls between 0 and +90 degrees, an often neglected criterion. This
produces upright P waves in lead II and inverted P waves in aVR.

9. Maintain ABC
If Hypoxemic, administer oxygen
Cardiac monitor – Identify rhythm
Monitor BP and SpO2
IV/IO access
Assess 12-lead ECG
Evaluate QRS duration
Rhythm with 12
lead ECG monitor
Possible Sinus
Tachycardia
Search for and treat
cause
Possible Supraventricular
Tachycardia
Stable Unstable
Ventricular
Tachycardia
Cardiopulmonary
Compromise
Synchronised
Cardioversion
Consider adenosine if
rhythm regular and
QRS monomorphic
Attempt vagal maneuvers
or adenosine
Synchronised
Cardioversion
Specialist Consultation
advised
Amiodarone
Procainamide
NARROW WIDE
YES
NO
NO
SYNCHRONISED CARDIOVERSION :
Begin with 0.5 to 1J/kg; if not effective,
2J/kg
Sedate if needed.
ADENOSINE IV/IO DOSE
1ST DOSE : 0.1mg/kg RAPID BOLUS (max
6mg)
2nd DOSE : 0.2mg/kg rapid bolus (max
12mg)
AMIODARONE IV/IO DOSE
5mg/kg over 20-60 minutes
PROCAINAMIDE IV/IO DOSE
15mg/kg over 30-60mins

10. Beat to beat variability occurs with change in activity
P waves present and normal
PR interval – constant and normal duration
RR interval – Variable
QRS Complex – Narrow

11. Maintain ABC
If Hypoxemic, administer oxygen
Cardiac monitor – Identify rhythm
Monitor BP and SpO2
IV/IO access
Assess 12-lead ECG
Evaluate QRS duration
Rhythm with 12
lead ECG monitor
Possible Sinus
Tachycardia
Search for and treat
cause
Possible Supraventricular
Tachycardia
Stable Unstable
Ventricular
Tachycardia
Cardiopulmonary
Compromise
Synchronised
Cardioversion
Consider adenosine if
rhythm regular and
QRS monomorphic
Attempt vagal maneuvers
or adenosine
Synchronised
Cardioversion
Specialist Consultation
advised
Amiodarone
Procainamide
NARROW WIDE
YES
NO
NO
SYNCHRONISED CARDIOVERSION :
Begin with 0.5 to 1J/kg; if not effective,
2J/kg
Sedate if needed.
ADENOSINE IV/IO DOSE
1ST DOSE : 0.1mg/kg RAPID BOLUS (max
6mg)
2nd DOSE : 0.2mg/kg rapid bolus (max
12mg)
AMIODARONE IV/IO DOSE
5mg/kg over 20-60 minutes
PROCAINAMIDE IV/IO DOSE
15mg/kg over 30-60mins

12. SUPRAVENTRICULAR TACHYCARDIA
Most common tachyarrhythmia that causes cardiovascular compromise during
infancy.

13. ECG signs
• No beat to beat variability
• >220/min in infants
• >180/min in children
• P waves absent or abnormal
• RR interval constant
• QRS complex narrow

14. Maintain ABC
If Hypoxemic, administer oxygen
Cardiac monitor – Identify rhythm
Monitor BP and SpO2
IV/IO access
Assess 12-lead ECG
Evaluate QRS duration
Rhythm with 12
lead ECG monitor
Possible Sinus
Tachycardia
Search for and treat
cause
Possible Supraventricular
Tachycardia
Stable Unstable
Ventricular
Tachycardia
Cardiopulmonary
Compromise
Synchronised
Cardioversion
Consider adenosine if
rhythm regular and
QRS monomorphic
Attempt vagal maneuvers
or adenosine
Synchronised
Cardioversion
Specialist Consultation
advised
Amiodarone
Procainamide
NARROW WIDE
YES
NO
NO
SYNCHRONISED CARDIOVERSION :
Begin with 0.5 to 1J/kg; if not effective,
2J/kg
Sedate if needed.
ADENOSINE IV/IO DOSE
1ST DOSE : 0.1mg/kg RAPID BOLUS (max
6mg)
2nd DOSE : 0.2mg/kg rapid bolus (max
12mg)
AMIODARONE IV/IO DOSE
5mg/kg over 20-60 minutes
PROCAINAMIDE IV/IO DOSE
15mg/kg over 30-60mins

15. ECG Signs
• Ventricular rate >120/min
• QRS complex wide
• P waves often not visible

16. Assessment of Rapid Heart Rate
• Does the patient have a pulse?
Absent Initiate the Pediatric Cardiac Arrest Algorithm
Present Proceed with the tachycardia algorithm.
• Is perfusion adequate or poor?
Poor Follow the Pediatric Tachycardia With a Pulse and Poor
Perfusion Algorithm
Adequate Follow the Pediatric Tachycardia With a Pulse and Adequate
Perfusion Algorithm.

17. • Is the QRS complex narrow or wide?
Narrow Consider the differential of sinus tachycardia versus SVT.
Wide Consider the differential of SVT versus VT, but treat as
presumed VT unless the child has known aberrant conduction.

18. Treatment of Tachyarrhythmias:
• Assess for signs of shock or hemodynamic instability.
• Support oxygenation and ventilation.
• Attach a monitor/defibrillator and pulse oximeter.
• Establish vascular access.
• Obtain a 15-lead ECG (12 standard leads plus V3R and V4R).
• Check potassium, glucose, ionized calcium, magnesium, and blood gas to
assess pH.
• Assess neurologic status for decreased consciousness.
• Prepare to give adenoside.
• Identify and treat reversible causes.

19. Indications for Synchronized cardioversion:
• Hemodynamically unstable patients (poor perfusion, hypotension, or heart
failure) with tachyarrhythmias (SVT, atrial flutter, VT) but with palpable pulses
• Elective cardioversion of stable SVT, atrial flutter, or ventricular tachycardia.

20. Cardioversion of Unstable SVT or VT With a Pulse
1. Turn on defibrillator.
2. Set lead switch to paddles.
3. Select adhesive pads or paddles. Use the largest pads or paddles that can fit on
the patient's chest without touching each other.
4. If using paddles, apply conductive gel or paste.
5. Administer sedation.
6. Select synchronized mode.
7. Select energy dose: Initial dose: 0.5-1 J/kg. Subsequent doses: 2 J/kg
8. Announce "Charging defibrillator," and press charge on the defibrillator
controls or apex paddle.

21. • 10. When the defibrillator is fully charged, state, "I am going to shock on
three." Then count, “1, 2, 3,” "All clear!"
• 11. After confirming all persons are clear of the patient, press the shock button.
12. Check the monitor. If tachycardia persists, increase the energy, reset the
synch mode, and cardiovert again.

22. Thank you.