svt in pediatrics

SupraventriculaSupraventricular Tachycardia in r Tachycardia in

PediatricPediatric

Cardiac arrhythmia

• is a abnormal electrical activity in the heart

• too fast or too slow

• regular or irregular.

DefinationDefination

OverviewOverview

Sinus tachycardiaSVTVFVTAtrial fibAtrial flutter

Sinus bradycardiaHeart block

Sinus arrhythmiaPACPVC

Tachycardia Bradycardia

Irregular

In structurally normal/ abnormal heartCongenital metabolic disorders of mitochondriaSLE

Rheumatic feverMyocarditisToxin (diphtheria)Pro-arrhythmic or anti-arrhythmic drugsSurgical correction of CHD

CongenitalCongenital AcquiredAcquired

Normal Heart Rate Normal Heart Rate Age Heart RateNewborn 120-160Infant 80- 140Toddler 1-3 yrs 80- 130Pre School 3-5yrs 80- 120School Age 6-12 yrs

70- 110

Adolescent 13+ 60- 100

Range from Completely asymptomatic Loss of consciousnessSudden cardiac death

In infantsLethargyPoor feedingIrritabilityCardiac failureUnderlying congenital

heart disease

In childrenPalpitationSyncopeDizzinessChronic fatigueShortness of breathChest discomfort

HistorySymptomsFrequency and length of episodeOnset and triggersAny underlying diseaseMedicationso Triggering factoro Used for underlying cardiac disease

Evaluation Child with Evaluation Child with ArrhythmiaArrhythmia

DiagnosisDiagnosisAlways do-12 Lead ECG!!!!!-During tachycardia-In sinus rhythm

Diagnostic methodsDiagnostic methods• Always• Always• Always record a rhythm

strip during any intervention (adenosine, cardioversion, Valsalva, etc.)

Diagnostic methodsDiagnostic methods• Holter• Event recorder• Exercise ECG• Post-op atrial/ventricular pacing wires• Esophageal pacing leads• Adenosine can be diagnostic• Invasive electrophysiology study

Sinus RhythmSinus RhythmEvery QRS complex is preceded by a P wave and every P wave must be followed by a QRS The P wave morphology and axis must be normal and PR interval will usually be normal for that age

Sinus ArrhythmiaSinus Arrhythmia

Most common irregularity of heart rhythm seen in childrenNormal variantHeart rate increases during inspiration and decreases during expiration

Sinus ArrhythmiaSinus Arrhythmia

Normal phasic variation of heart rate with respiration

Variable P-P intervals

No treatment needed

TachyarrhythmiaTachyarrhythmia

• Supraventricular Tachycardia• Ventricular Tachycardia

Basic Mechanism of Basic Mechanism of TachycardiaTachycardia

1.Re- entry – most common2.Automaticity3.Triggered activity - rare

Re – entry TachycardiaRe – entry Tachycardia

AutomaticityAutomaticity

SVTSVTMost common abnormal tachycardia seen in pediatric practiceMost common arrhythmia requiring treatment in pediatric populationMost frequent age presentation: 1st 3 months of life 2nd peaks @ 8-10 and in adolescence

SVTSVTCommonest mechanism – re-entry- Accessory pathway – 80%-AV nodal re-entry – 20%

-Younger age – accessory pathway-Older age - AVNRT

SVT - classificationSVT - classificationAV node Dependent Tachycardia

AV Node independent Tachycardia

AVRT - concealed pathway - manifest pathway -WPW syndrome

Sinus node reentrant Tachycardia

AVNRT - Typical ( slow-fast) - Atypical (Fast-slow)

Atrial Tachycardia - Focal atrial tachycardia - Multifocal atrial tachycardia

Juctional Ectopic Tachycardia ( JET)

Atrial Flutter

Permanent Juctional Reciprocating Tachycardia ( PJRT)

Atrial Fibrillation

P wave in TachycardiaP wave in Tachycardia- Important to identify p wave during the

tachycardia- Helps to guide types of SVT

- No p wave- Short RP tachycardia- Long RP tachycardia

P wave in TachycardiaP wave in TachycardiaNo visible p Wave, narrow complex- AVNRT

P wave in Tachycardia P wave in Tachycardia – Short RP– Short RP

- AVRT- Typical AVNRT

P wave in Tachycardia P wave in Tachycardia – Short RP– Short RP

P wave in Tachycardia P wave in Tachycardia – Long RP– Long RP

- Atypical AVNRT- PJRT- Atrial tachycardia- Sinus tachycardia- sinus node tachycardia

P wave in Tachycardia P wave in Tachycardia – Long RP– Long RP

What's Next?What's Next?LOOK FOR THE R-R interval

- regular- irregular

Gives clues on types of SVT

ANRT - P wave on ST ANRT - P wave on ST segmentsegment

Regular R-R intervalRegular R-R interval

AVNRT - p wave absent AVNRT - p wave absent or pseudo r wave on VI or pseudo r wave on VI

Regular R-R intervalRegular R-R interval

AET - Long RP AET - Long RP tachycardia with tachycardia with abnormal p wave abnormal p wave

morphology morphology Regular R-R intervalRegular R-R interval

PJRT -Long RP PJRT -Long RP tachycardia with tachycardia with abnormal p wave abnormal p wave

inverted lead II,III,aVF inverted lead II,III,aVF Regular R-R intervalRegular R-R interval

Atrial flutter – saw tooth Atrial flutter – saw tooth baselinebaseline

MET – Irregular MET – Irregular TachycardiaTachycardia

Long RPLong RPdifferent p wave different p wave

morphologymorphology

JET – Irregular R-R JET – Irregular R-R intervalinterval

p wave with VA p wave with VA dissociationdissociation

ManagementManagementTreatment Option SVT Termination

1.Vagal maneuvers2.Anti arrhythmic drugs ( IV or Oral )3.Electrical Termination

- DC cardioversion- Endocardial pacing- Trans Esophageal pacing

ManagementManagement

ManagementManagementVagal Maneuvers

1.Smaller childrens and infants- Ice cold facecloth to the face- Stimulate the vagal response

1.Older childrens- carotid massage- Valsalva technique

Management - IV Management - IV AdenosineAdenosine

• Diagnostic and therapeutic

• Given via central line better than peripheral

• Short half life

• 100-500mcg/kg given rapid IV push

• ALWAYS!!! Record rhythm strip during adenosine

Adenosine Response Adenosine Response

Adenosine responseAdenosine response

Adenosine ResponseAdenosine Response

SVT TreatmentSVT Treatment1. IV Verapamil – older childrens 0.1mg/kg

- Contraindicated in < 4 yrs old and in WPW syndrome

2. Digoxin – useful in infants- Contraindicated in WPW

3. IV propranolol 0.1mg/kg4. IV Flecanaide 0.5-2mg/kg5. IV amiodarone 5mg/kg in 30min and

5-15mcg/kg/min6. Cardioversion 0.5-2J/kg

Management- Management- PreventionPrevention

1.No treatment2.Anti Arrhythmic drug3.Radiofrequency ablation

Management - Management - PreventionPrevention

No Treatment

-Infrequent eposides-Explain -Educate on valsalva-PRN treatment in ED

Management - Management - PreventionPrevention

Management - Management - PreventionPrevention

Treatment OptionsTreatment Options1. AV node

- Digoxin- Class II – beta blockers- Class III – Amiodarone- Class IV – Verapamil

2. Accessory pathway- Class 1C – Flecanaide- Class III – Amiodarone- WPW- No Verapamil or Digoxin

Management - Management - PreventionPrevention

Radiofrequency Ablation

– invasive procedure- Curative -Older children's-Incessant SVT- PJRT-Symptomatic SVT-Drug refractory SVT-WPW with symptomatic

SummarySummary• SVT generally well tolerated, life threatening is

uncommon

• Record 12 lead ECG during arrhythmia

• Record rhythm strip during any intervention

• ECG clue for diagnosis – wide or narrow complex, p wave relationship to QRS and regular or irregular rhythm

• Proper diagnosis can guide appropriate Tx

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