Pediatric Pediatric DysrhythmiasDysrhythmias

Dr.B.BALAGOBIDr.B.BALAGOBI

Pediatric dysrhythmiasPediatric dysrhythmiasTreatment not Treatment not requiredrequired

Treatment Treatment isis required required

Sinus arrhythmiaSinus arrhythmia Supraventricular Supraventricular tachycardiatachycardia

Wandering atrial Wandering atrial pacemakerpacemakerIsolated premature atrial Isolated premature atrial contractionscontractionsIsolated premature Isolated premature ventricular contractionsventricular contractions

Ventricular tachycardiaVentricular tachycardia

First degree AV blockFirst degree AV block Third degree AV block Third degree AV block with symptomswith symptoms

Reproduced from Zitelli’s Atlas of Pediatric physical diagnosis, 2007, pg 140.

Pediatric dysrhythmiasPediatric dysrhythmias Vital to be aware of arrhythmias that Vital to be aware of arrhythmias that

occur in otherwise healthy childrenoccur in otherwise healthy children Management is individualizedManagement is individualized Does child have history of heart Does child have history of heart

disease?disease? Are symptoms present?Are symptoms present?

Sinus arrhythmiaSinus arrhythmia Most common irregularity of heart Most common irregularity of heart

rhythm seen in childrenrhythm seen in children Normal variantNormal variant Reflects healthy interaction between Reflects healthy interaction between

autonomic respiratory and cardiac autonomic respiratory and cardiac control activity in CNScontrol activity in CNS

Heart rate increases during inspiration Heart rate increases during inspiration and decreases during respirationand decreases during respiration

Sinus arrhythmiaSinus arrhythmia

First degree AV blockFirst degree AV block Commonly seen (up to 6% normal Commonly seen (up to 6% normal

neonates)neonates) PR interval is greater than upper limits of PR interval is greater than upper limits of

normal for a given agenormal for a given age PR interval is age and rate dependentPR interval is age and rate dependent 70-170 msec in newborns is normal70-170 msec in newborns is normal 80-220 msec in young children and adults80-220 msec in young children and adults Generally does not cause bradycardia Generally does not cause bradycardia

since AV conduction remains intactsince AV conduction remains intact

First degree AV blockFirst degree AV block Diseases that can be associated with Diseases that can be associated with

first degree AV block: rheumatic first degree AV block: rheumatic fever, rubella, mumps, hypothermia, fever, rubella, mumps, hypothermia, cardiomyopathy, electrolyte cardiomyopathy, electrolyte disturbancesdisturbances

Third degree AV blockThird degree AV block AKA complete heart blockAKA complete heart block Most common cause of abnormal Most common cause of abnormal

bradycardia in infants and childrenbradycardia in infants and children Complete disassociation between P Complete disassociation between P

waves and QRS complexeswaves and QRS complexes

Third degree AV blockThird degree AV block Can be congenital – in this case it is Can be congenital – in this case it is

strongly associatedstrongly associated with maternal with maternal SLESLE

Mom of an infant should be worked Mom of an infant should be worked upup

Most common structural heart defect Most common structural heart defect associated is corrected transposition associated is corrected transposition of great vesselsof great vessels

Third degree AV blockThird degree AV block May be asymptomatic – follow clinicallyMay be asymptomatic – follow clinically Slower the heart rate, and wide QRS Slower the heart rate, and wide QRS

escape rhythms place into high risk groupescape rhythms place into high risk group May need implantable pacemaker: May need implantable pacemaker:

significant bradycardias, syncope, exercise significant bradycardias, syncope, exercise intolerance, ventricular dysrhythmias, or intolerance, ventricular dysrhythmias, or ventricular arrhythmias, structural diseaseventricular arrhythmias, structural disease

Possible acute treatment: isoproterenolPossible acute treatment: isoproterenol

Supraventricular Supraventricular tachycardiatachycardia

Most common abnormal tachycardiaMost common abnormal tachycardia seen in pediatric practiceseen in pediatric practice

Most common arrhythmia requiring Most common arrhythmia requiring treatmenttreatment in pediatric population in pediatric population

Most frequent age presentation: 1Most frequent age presentation: 1stst 3 3 months of life, 2months of life, 2ndnd peaks @ 8-10 and in peaks @ 8-10 and in adolescenseadolescense

Rapid, Rapid, regularregular, usually narrow QRS , usually narrow QRS rhythm, originating above the ventricles rhythm, originating above the ventricles

SVTSVT

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

SVTSVT Paroxysmal, sudden onset & offset Paroxysmal, sudden onset & offset Rates of SVT vary with ageRates of SVT vary with age Overall average rate for all ages: 235 bpmOverall average rate for all ages: 235 bpm

– 11stst 9 months of life: avg rate is 270 bpm 9 months of life: avg rate is 270 bpm– Older children: avg rate is 210 bpm( 180-250)Older children: avg rate is 210 bpm( 180-250)

P waves difficult to define, but 1:1 with P waves difficult to define, but 1:1 with QRSQRS

Important to differentiate from sinus tachImportant to differentiate from sinus tach

SVTSVT Older kids can describe a sensation Older kids can describe a sensation

of a fast heart rate, palpitations, or of a fast heart rate, palpitations, or chest tightnesschest tightness

Hemodynamic compromise in Hemodynamic compromise in newborns and those with structural newborns and those with structural heart diseaseheart disease

Those with typical symptoms would Those with typical symptoms would benefit from cardiac consultationbenefit from cardiac consultation

SVT - TreatmentSVT - Treatment Goal: identify unstable patients, differentiate from Goal: identify unstable patients, differentiate from

sinus tachycardia, and terminate the rhythm sinus tachycardia, and terminate the rhythm Vagal maneuvers in stable patients(successful in 80%)Vagal maneuvers in stable patients(successful in 80%)

– Carotid sinus massageCarotid sinus massage– Ice pack on faceIce pack on face

Adenosine if IV access readily available(Rx of choice)Adenosine if IV access readily available(Rx of choice)– Stop conduction through AV nodeStop conduction through AV node– Helps to define p waves if unsure of etiologyHelps 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 0.1 mg/kg (max 6 mg), repeat 0.2 mg/kg ( max 12 mg) in line

closest to central circulationclosest to central circulation– Need continuous ECG and BP monitoringNeed continuous ECG and BP monitoring

Synchronized cardioversionSynchronized cardioversion Amiodarone, Procainamide if above unsuccessfulAmiodarone, Procainamide if above unsuccessful Transesophageal atrial pacing can also be performedTransesophageal atrial pacing can also be performed

SVT - TreatmentSVT - Treatment Need post conversion ECG – identify those with Need post conversion ECG – identify those with

WPW syndrome ( 25 % pts with SVT)WPW syndrome ( 25 % pts with SVT) Will also need an echo – identify structural Will also need an echo – identify structural

problemsproblems Radiofrequency catheter ablationRadiofrequency catheter ablation

– Frontline treatmentFrontline treatment– Very effectiveVery effective– Cutoff points usually are 5 y.o. and 15 kg, unless Cutoff points usually are 5 y.o. and 15 kg, unless

severe SVTsevere SVT Observation and expectant managementObservation and expectant management MedicationsMedications

– Digoxin and beta blockers as first lineDigoxin and beta blockers as first line– Flecainide, sotalol, amiodaroneFlecainide, sotalol, amiodarone

SVT - WPWSVT - 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.

Ventricular tachycardiaVentricular tachycardia Sustained V-tach is uncommon, needs Sustained V-tach is uncommon, needs

workupworkup Regular Regular widewide complex tachycardia complex tachycardia Atrioventricular dissociation Atrioventricular dissociation Life threatening arryhthmiaLife threatening arryhthmia Often presents in those who have had Often presents in those who have had

open heart surgical repair, or those with open heart surgical repair, or those with cardiomyopathies, myocarditis, or cardiomyopathies, myocarditis, or tumorstumors

V-TachV-Tach Treatment: IV lidocaine, Treatment: IV lidocaine,

procainamide, amiodaroneprocainamide, amiodarone If critically ill: synchronized If critically ill: synchronized

cardioversioncardioversion Long term: meds, ablation, or Long term: meds, ablation, or

defibrillatordefibrillator

Ventricular fibrillationVentricular fibrillation Seen in children with EKG Seen in children with EKG

abnormalities such as long QT abnormalities such as long QT syndrome, or Brugada syndromesyndrome, or Brugada syndrome

Cardiomyopathies, structural heart Cardiomyopathies, structural heart disease causing ventricular disease causing ventricular dysfunctiondysfunction

Treatment: immediate defibrillation, Treatment: immediate defibrillation, CPRCPR

Sinus tachycardia can be associated Sinus tachycardia can be associated with :with :

a) Fevera) Fever b) Hemorrhageb) Hemorrhage c) Exercisec) Exercise d) Breath holdingd) Breath holding e) Anxietye) Anxiety f)anaemiaf)anaemia

A 6-week-old infant is brought to the well-A 6-week-old infant is brought to the well-baby visit. nurse discovers a rapid heart baby visit. nurse discovers a rapid heart rate. The ECG shows a regular, narrow rate. The ECG shows a regular, narrow QRS tachycardia with a rate of 260 QRS tachycardia with a rate of 260 beats/minute. Appropriate therapy for this beats/minute. Appropriate therapy for this problem could include all of the followingproblem could include all of the following

a) Intravenous administration of adenosinea) Intravenous administration of adenosine b) Placing an examination glove filled with b) Placing an examination glove filled with

ice over the infant's foreheadice over the infant's forehead c) Intravenous administration of verapamilc) Intravenous administration of verapamil d) Application of gentle abdominal d) Application of gentle abdominal

pressure to mimic a Valsalva maneuverpressure to mimic a Valsalva maneuver e)Cardioversione)Cardioversion

T/F concerning congenital T/F concerning congenital complete heart bockcomplete heart bock

a) It can be associated with maternal a) It can be associated with maternal systemic lupus erythematosus.systemic lupus erythematosus.

b) It can be associated with complex b) It can be associated with complex congenital heart disease.congenital heart disease.

c) It is typically treated with a cardiac c) It is typically treated with a cardiac pacemaker.pacemaker.

d) The ECG typically demonstrates a d) The ECG typically demonstrates a prolonged PR interval.prolonged PR interval.

E)associated with TGAE)associated with TGA

Causes for syncope in Causes for syncope in children are?children are?

a) Severe aortic stenosisa) Severe aortic stenosis b) Long QT syndromeb) Long QT syndrome c) Seizure disorderc) Seizure disorder d) Fluid depletiond) Fluid depletion e) Hypoglycemiae) Hypoglycemia f)Breath-holding spellsf)Breath-holding spells g) Hypertrophic cardiomyopathyg) Hypertrophic cardiomyopathy h) Neurocardiogenic syncopeh) Neurocardiogenic syncope