Cardiac Arrhythmias in infants & children

Dr Aly MA EL-Mohsen, MD ELLecturer in Pediatrics, Alexandria University

Impulse formation & conduction

Recording ECG 

Leads (I , II, III)  Augmented leads (avL, avR, avF)  Chest (precordial) leads (V1 ± V6) (V1

Limb leads

Augmented leads

Precordial leads

Waves, intervals & segments

avR V 1-2


I, II, III, avL, avF V3-6

-----------------------------------++++++++++++++++++++++++++++++++++++++ K+ ++++++++++++++++++++++++++++++++++++++ ------------------------------------

ECG wave Generation

Wave generation continued

Wave generation continued

Wave generation continued

Cardiac cycle

Estimation of the HR

HR =

300 Number of large squares

Finding the P wave

Aetiology of arrhythmias 

Congenital heart diseases. Myocarditis (e.g. viral myocarditis) Cardiomyopathy. PostPost-operatively. DrugDrug-induced (e.g. digitalis). Electrolyte disturbances. Endocrinal & metabolic diseases. Cardiac tumours (rhabdomyoma or myxoma)


Abnormal impulse formation

Abnormal impulse conduction

Abnormal impulse formation
‡ Sinus tachycadia. ‡ Sinus bradycardia. ‡ Premature atrial complexes ‡ Supraventricular tachycardia. ‡ Junctional rhythm or tachycardia. ‡ Atrial flutter & fibrillation.

‡ Premature ventricular complexes.

‡ Ventricular tachycardia. ‡ Ventricular fibrillation.

Sinus Tachycardia

Sinus tachycardia

Sinus bradycardia

Premature atrial complexes

APCs continued

Blocked PACs

Supraventricular Tachycardia



Ectopic atrial tachy.

AV node

Accessory pathway

Reentry Tachycardia

Supraventricular Tachycardia   


The most frequent sustained arrhythmia in pediatrics. May start to occur in-utero, neonatal, infancy or inchildhood. HR is regular & rapid 240-300 bpm. 240Attacks starts suddenly & last for period of few seconds up to several weeks. Heart failure may eventually occur.

12-lead ECG (SVT) 12-

Clinical features of SVT 

In newborn & infants:
Sudden pallor, tachyapnea & refusal of feeding.  Baby is usually restless & very irritable.  Very rapid HR with cardiomegaly & hepatomegaly.  

In older children: 

Child may be aware of the onset of the fast heart rate & become anxious & apprehensive.

Treatment of SVT 

Vagal stimulation. Adenosine: (adenocor 3mg/ml)  

IV 50 ± 100 mcg/kg , can be repeated/2min with 50 repeated/2 mcg/kg increase in dose up to 3 times. NOT in WPW 


Digitalization at 0.02 ± 0.035 mg/kg/day ÷ 3 doses IV. maintenance : 0.01 mg/kg/day ÷ 2 dose orally (for 1 year)

Treatment of SVT continued 

Beta blockers: 

Inderal (propranolol)
IV slowly 0.02 - 0.05 mg/kg can be repeated/ 6-8 hrs.  Orally 0.2 ± 0.5 mg/kg t.d.s for maintenance.  

Esmolol : (brevibloc) 

IV bolus 0.5 mg/kg then 50 mcg/kg/min IV infusion.

Treatment of SVT continued 

Amiodarone: Amiodarone: (cordarone)
IV 5mg/kg over 20 minutes followed by IV infusion of 0.3 ± 0.9 mg /kg/hr.  Orally 5 mg /kg twice daily for 7-10 days then 5-10 /kg daily.  

Flecainide: Flecainide:
IV 2 mg/kg over 10 -30 mins then 0.1 -0.2 mg/kg/hr until arrhythmia stops.  Orally 2 mg /kg 2-3 times daily. 

Treatment of SVT continued 

Verapamil : (in older children)
IV: Given over 2±3 minutes in dose of 0.1±0.3 mg/kg, using continuous ECG monitoring. May repeat once after 30 mins. max dose: 5 mg.  PO: Children: 4±8 mg/kg/24 hr ÷ TID mg/kg/24  

DC shock:
For unresponsive hemodynamically compromised infants & children with SVT.  0.5±2 watt-sec/kg. watt

Treatment of SVT continued

TwentyTwenty-four hour electrocardiographic (Holter) recordings are useful in monitoring the course of therapy and in detecting brief runs of asymptomatic tachycardia .  Radiofrequency ablation of an accessory pathway : 1- multiple agents are required or 2- drug side effects are intolerable 3- arrhythmia control is poor. The overall initial success rate ranges from approximately 80% to 95%, depending on the location of the bypass 80% 95%, tract or tracts. 

Premature Ventricular Complexes

Dangerous types: (1) two or more ventricular premature beats in a row. (2) multifocal origin. (3) increased ventricular ectopic activity with exercise. (4) R on T phenomenon (PVC occurs on the T wave of the preceding beat). (5) Presence of underlying heart disease

Premature Ventricular Complexes

Ventricular Tachycardia

Ventricular tachycardia


12-lead ECG (VT) 12-



Treatment of Vent arrhythmias 


IV 0.5 ± 1 mg /kg then 0.6 ± 3 mg/kg/hr by infusion. 

Amiodarone intravenously. DC shock (0.5±2 watt-sec/kg) . (0 watt-

Viral Myocarditis 

Etiology: Etiology: 

Coxsackie B virus. Adenovirus Breathlessness on exertion & feeding. Excessive sweating. Irritability & weak cry. Tachycardia Tachyapnea. Gallop rhythm. 

Clinically: Clinically: 

Enlarged tender liver.  Edema.  

Cardiomegaly.  Congested lung fields.  

Low voltage ECG.  ST segment changes.  

Treatment: Treatment: 

Diuretics. Digitalis. Captopril.

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