Arrhythmias

Nightfloat Curriculum 2010-2011 LPCH Pediatric Residency Program

By Jennifer Everhart, MD

Learning Objectives
Recognize common pediatric cardiac arrhythmias Recognize early signs of clinical decompensation/hemodynamic instability Initiate management of arrhythmias in the inpatient setting, including identifying and treating reversible causes Review PALS algorithms for bradycardia & tachycardia

Bradyarrhythmias - Symptoms
General: altered LOC, fatigue, lightheadedness, dizziness, syncope Hemodynamic instability: hypotension, poor end-organ perfusion, respiratory distress/failure, sudden collapse

Bradyarrhythmias - Causes
1: Abnormal pacemaker/conduction system (congenital or postsurgical injury), cardiomyopathy, myocarditis 2: Reversible Hs & Ts:
Hypoxia Hypotension H+ ions (acidosis) Heart block Hypothermia Hyperkalemia Trauma (head) Toxins/drugs (cholinesterase inhibitors, Ca++ channel blockers, adrenergic blockers, digoxin, central 2-adrenergic agonists, opioids)

Bradyarrhythmias - Types
Sinus bradycardia
Physiologic (ie: sleep, athletes) vs. pathologic (ie: abnormal lytes, infection, drugs, hypoglycemia, hypothyroidism, ICP)

Sinus node block

Junctional beat

Subsidiary pacemakers lead to atrial, junctional, & idioventricular escape rhythms

Bradyarrhythmias AV Blocks
Type
1st degree

EKG Findings
Prolonged PR interval

Causes & Clinical Significance

Causes include AV nodal disease, vagal tone, myocarditis, abn electrolytes (ie: K+), MI, drugs (ie: Ca++ channel blockers, -blockers, digoxin), acute rheumatic fever. Usually asymptomatic. Usually due to block within AV node. Caused by parasympathetic tone, MI, drugs (ie: Ca++ channel blockers, -blockers, digoxin). Can cause dizziness. Typically transient and benign; rarely progresses to 3rd degree heart block. Usually caused by defect in conduction pathway or acute coronary syndrome, leading to block below AV node & His bundle. Symptoms include palpitations, presyncope, syncope. Can progress to 3rd degree heart block; often requires pacemaker. Congenital or caused by conduction system disease or injury (ie: surgery, MI). Most symptomatic form of heart block: fatigue, presyncope, syncope. Usually requires pacemaker (especially if acquired).

2nd degree
Mobitz type I Wenchebach

Progressive prolongation of PR interval until atrial impulse not conducted to ventricles Constant prolongation of PR interval, inhibition of a set proportion of atrial impulses AV dissociation. No atrial impulses are conducted to the ventricle

2nd Degree
Mobitz type II

3rd Degree
complete

1st degree heart block

2nd degree heart block, Mobitz I

2nd degree heart block, Mobitz II

3rd degree heart block

Bradyarrhythmias - Management
Stable patients:
12 lead EKG, +/- labs, consult cardiology

Unstable patients:
ABCs PALS Pediatric Bradycardia Algorithm

Address reversible causes (Hs & Ts)

Tachyarrhythmias - Symptoms
General: palpitations, lightheadedness, syncope, fatigue, SOB, chest pain
Infants: poor feeding, tachypnea, irritability, sleepiness, pallor, vomiting

Hemodynamic instability: respiratory distress/failure, hypotension, poor endorgan perfusion, altered LOC, sudden collapse

Tachyarrhythmias - Causes
1: Underlying conduction abnormalities 2: Reversible Hs & Ts
Hypovolemia Toxins Hypoxia Tamponade (cardiac) H+ ions (acidosis) Tension pneumothorax Hypoglycemia Thrombosis (coronary, pulmonary) Hypothermia Trauma Hypo/Hyperkalemia

Tachyarrhythmias - Classification
Narrow complex: sinus tachycardia, supraventricular tachycardia, atrial flutter Wide complex: ventricular tachycardia, supraventricular tachycardia with aberrant intraventricular conduction

Tachyarrhythmias - Types
Sinus tachycardia
Usually <220 bpm in infants, <180 bpm in children P waves present and normal (upgoing in I, II, AVF), narrow QRS, beat to beat variability Response to bodys need for increased cardiac output or oxygen delivery (ie: hypoxia, hypovolemia, fever, pain, anemia)

Tachyarrhythmias - Types
Supraventricular tachycardia
>220 bpm in infants, >180 bpm in children Abrupt onset; occurs intermittently Usually narrow QRS, absent or abnormal P waves, no beat to beat variability Caused by accessory pathway reentry (ie: WPW), AV nodal reentry, ectopic atrial focus

Tachyarrhythmias - Types
Atrial flutter
Sawtooth pattern on EKG Atrial rate 350-400/min; ventricular rate varies

Ventricular tachycardia
Wide QRS (>0.08 sec), P waves may be unidentifiable or not related to QRS Caused by underlying heart disease, post-heart surgery, myocarditis, cardiomyopathy, QTc, K+, Ca++, Mg++, drug toxicity

Tachyarrhythmias - Types
Torsades de Pointes
Variable polarity & amplitude of QRS, appearing to rotate around the EKG isoelectric line A type of polymorphic VT Caused by long QT syndromes, Mg++, drug toxicities (including antiarrhythmics) Can deteriorate to ventricular fibrillation

Tachyarrhythmia vs. Artifact

Differentiating arrhythmia from artifact:
Sharp spikes from QRS complexes superimposed on arrhythmia Wandering baseline Normal QRS complexes in some leads

Causes of artifact:
Simultaneous use of other equipment, muscle contractions, movement

Tachyarrhythmias - Management
ABCs If pulse PALS tachycardia algorithms
Poor perfusion Pediatric Tachycardia With Pulses and Poor Perfusion algorithm Adequate perfusion Pediatric Tachycardia With Adequate Perfusion algorithm

If no pulse PALS Pediatric Pulseless Arrest algorithm

Tachyarrhythmias - Management
In general
Attach monitor/defibrillator, pulse ox; establish vascular access Obtain appropriate labs (ie: blood gas, lytes) Identify & treat any reversible causes

Torsades de Pointe or VT due to Mg++

Magnesium sulfate

Tachyarrhythmias Management
SVT with adequate perfusion
Vagal maneuvers while preparing adenosine

SVT with poor perfusion

Immediate adenosine or cardioversion
Consider vagal maneuvers if no delay

Adenosine
Rapid bolus then flush using proximal PIV or CVL 0.1 mg/kg; max 1st dose 6 mg; additional 0.2 mg/kg if needed (max 2nd dose 12 mg)

Cardioversion (0.5-1 J/kg; sedate if possible)

Case #1
9 year old boy admitted for asthma exacerbation, noted to have heart rate of 55.

Case #2
3 month old girl brought to ED for poor feeding and fussiness, noted to have heart rate of 230.

References
American Heart Association. 2005 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric and Neonatal Patients: Pediatric Advanced Life Support. Pediatrics 2006;117;e1005-1028. Fleisher GR, et al. Textbook of Pediatric Emergency Medicine 5th Edition. Lippincott Williams & Williams, 2006. Pediatric Advanced Life Support. American Heart Association, 2006. Thaler MS. The Only EKG Book Youll Ever Need 4th Edition. Lippincott Williams & Williams, 2003. Zaoutis LB and Chiang VW. Comprehensive Pediatric Hospital Medicine. Mosby Elsevier, 2007.