PERWAKILAN V MALANG

SVT PADA BAYI DAN ANAK

DALAM PRAKTEK SEHARI-
HARI: diagnosis dan tatalaksana
awal
dr. E.S Zul Febrianti, SpA(K) M.Biomed

PEDIATRIC CARDIOLOGY UPDATE

SVT PEDIATRIC CARDIOLOGY UPDATE

Most common abnormal tachycardia seen in

pediatric practice
Most common arrhythmia requiring treatment
in pediatric population
Most frequent age presentation:
1st 3 months of life
2nd peaks @ 8-10 and in adolescence
Tachyarrhythmia Classification PEDIATRIC CARDIOLOGY UPDATE

1. Site of Origin
Atrium
SA Node • AET
• Sinus Node
• MAT
dysfunction • Atrial Fibrillation
• Sick Sinus Syndrome
• Atrial Flutter
• SA Nodal Reentry
tachycardia

AV Node/ Junctional
• AVRT
• ANVRT Ventricle
• Junctional • VT
Tachycardia • VF
• PJRT
Classification PEDIATRIC CARDIOLOGY UPDATE

2. Anatomical Classification

SVT

His Bundle

VT
Classification PEDIATRIC CARDIOLOGY UPDATE

3. Functional Mechanism
• Re-entry –
• AVRT, AVNRT

• Automaticity
• AF, AET,MAT

• Triggered activity
• rare
SVT PEDIATRIC CARDIOLOGY UPDATE

1. AV re-entry tachycardia (70%) – most common

type

2. AV Nodal Re-entry tachycardia (12%) – more

common in older children

3. Atrial tachycardia ( 14%)

Atrial flutter
Ectopic atrial tachycardia
Multifocal atrial tachycardia
Atrial fibrillation
4. Junctional Ectopic Tachycardia
Causes PEDIATRIC CARDIOLOGY UPDATE

Re-entrant congenital conduction pathway

abnormality (common)

Poisoning

Metabolic disturbance

After cardiac surgery

Cardiomyopathy

Long QT syndrome

Drugs

Myocarditis
Causes PEDIATRIC CARDIOLOGY UPDATE

Secondary: Reversible Hs & Ts

Hypovolemia
Hypoxia
H+ ions (acidosis)
Hypoglycemia
Hypothermia
Hypo/Hyperkalemia
Thrombosis(coronary, pulmonary)
Toxins
Tamponade
Tension pneumothorax
Trauma
Evaluation PEDIATRIC CARDIOLOGY UPDATE

History
Symptoms : tachycardia, dizziness, shortness of breath,
sweating, fainting or near fainting
Frequency and length of episode  episodes
associated with exercise activity, caffeine
Onset and triggers
Any underlying disease
Medications
Triggering factor
Used for underlying cardiac disease
Red flags PEDIATRIC CARDIOLOGY UPDATE

• History of cardiac disease/ post cardiac

surgery
• Family history of sudden cardiac death
• Recurrent episodes
• Exertional syncope or palpitation
• Sudden abrupt LoC
• LoC associated is body injury
• Syncope Associated chest pain / palpitations
• Medications
 PEDIATRIC CARDIOLOGY UPDATE

Approach To SVT
Diagnosing Types of SVT PEDIATRIC CARDIOLOGY UPDATE

Gives a guide on treatment and management

ALWAYS DO 12 LEADS ECG

( in hemodynamic stable pt)
Steps Reading ECG in SVT PEDIATRIC CARDIOLOGY UPDATE

1. Is the QRS complexes narrow or broad?

2. Is the QRS regular or irregular?

3. Is the p Wave seen?

4. If the p wave seen, what's the relation to

QRS?
1. QRS complex narrow or broad? PEDIATRIC CARDIOLOGY UPDATE

• Narrow complex tachycardia • Wide complex tachycardia

2. Is the QRS regular or irregular? PEDIATRIC CARDIOLOGY UPDATE

Regular QRS complexes

Irregular QRS complexes

Narrow Complex Tachycardia PEDIATRIC CARDIOLOGY UPDATE

REGULAR QRS Irregular QRS

• Atrial fibrillation
• Sinus tachycardia • Atrial flutter with variable
• AVRT block
• AVNRT • Multifocal atrial tachycardia
• Junctional tachycardia • Junctional Ectopic
• Atrial tachycardia tachycardia
• Atrial flutter
• PJRT
Narrow Complex, Regular R-R interval PEDIATRIC CARDIOLOGY UPDATE
Narrow Complex, Irregular R-R interval PEDIATRIC CARDIOLOGY UPDATE
 PEDIATRIC CARDIOLOGY UPDATE

p wave not visible

Retrograde p wave

Multiple p waves
SVT
PEDIATRIC CARDIOLOGY UPDATE
Narrow complex, absent p wave PEDIATRIC CARDIOLOGY UPDATE
Narrow complex, retrograde p wave PEDIATRIC CARDIOLOGY UPDATE
4. p wave relation to QRS? PEDIATRIC CARDIOLOGY UPDATE

Identify p wave and assess the relation to R

wave

Classify to -Short RP tachycardia

Long RP tachycardia
4. p wave relation to QRS? PEDIATRIC CARDIOLOGY UPDATE
Narrow Complex, Regular RR interval,
Short RP tachycardia PEDIATRIC CARDIOLOGY UPDATE
P wave in Tachycardia – Long RP PEDIATRIC CARDIOLOGY UPDATE

-Atypical AVNRT
-PJRT
-Atrial tachycardia
-Sinus tachycardia
-sinus node tachycardia
Narrow Complex, Regular RR interval,
Long RP Tachycardia
PEDIATRIC CARDIOLOGY UPDATE
 PEDIATRIC CARDIOLOGY UPDATE

Rate – 200bpm
QRS – narrow complex and regular R-R interval
P wave not visible
SVT - AVRT, AVNRT, atrial or juctional tachycardia
 PEDIATRIC CARDIOLOGY UPDATE

Rate – 300bpm
QRS – narrow complex and regular R-R interval
P wave – visible and retrograde
Short RP tachycardia

Diagnosis : AVRT
 PEDIATRIC CARDIOLOGY UPDATE

Rate – 200bpm
QRS – Narrow complex, regular R-R interval
P wave not easily seen
Pseudo r wave in V1 and pseudo s in II
Diagnosis : AVNRT
 PEDIATRIC CARDIOLOGY UPDATE

• Narrow complex tachycardia, Regular R-R interval

• p wave seen
• p axis and morphology usually abnormal – positive in I, aVF but negative in V1

• Diagnosis : AET , Can be difficult to differentiate from ST

 PEDIATRIC CARDIOLOGY UPDATE

• Narrow complex tachycardia

• p wave seen
• Abnormal p wave – negative p in lead I, II – ectopic atrial
conduction
Atrial Ectopic Tachycardia
 PEDIATRIC CARDIOLOGY UPDATE

• Narrow complex tachycardia

• Irregular R-R interval
• p wave seen but multiple morphology
MULTIFOCAL ATRIAL TACHYCARDIA
 PEDIATRIC CARDIOLOGY UPDATE

• Narrow complex tachycardia

• Irregular R-R interval
• p wave seen with high rate, “sawtooth” pattern
• 2:1 AV conduction

ATRIAL FLUTTER WITH 2:1 block

 PEDIATRIC CARDIOLOGY UPDATE

• Narrow complex tachycardia

• p wave seen with high rate, “sawtooth” pattern
• 3:1 AV conduction
 PEDIATRIC CARDIOLOGY UPDATE

• Narrow complex, irregularly irregular rhythm

• No p wave seen, chaotic atrial activity
• Fibrillating wave maybe confused with p wave

ATRIAL FIBBRILATION
 PEDIATRIC CARDIOLOGY UPDATE

• Narrow complex tachycardia

• R-R interval can be regular or irregular
• p wave slower that QRS, vent rate > atrial rate
• AV dissociation
JUNCTIONAL ECTOPIC TACHYCARDIA
 PEDIATRIC CARDIOLOGY UPDATE

• Narrow complex
• Regular R-R interval
• p wave seen, Long RP tachycardia
• Inverted p wave in II, III and aVF

Permanent Junctional Reciprocating Tachycardia (PJRT)

Approach Child in Arrhythmias PEDIATRIC CARDIOLOGY UPDATE

1. Airway – secure
2. Breathing – oxygen
3. Circulation – check HR and presence of shock

Check for rhythm

• Too fast or too slow
• Narrow complex or broad complex tachycardia
• Regular or irregular rhythm
• Shock present or not?
PEDIATRIC CARDIOLOGY UPDATE
 PEDIATRIC CARDIOLOGY UPDATE

• Valsalve maneuvere

Stable • Carotid sinus massage

• Adenosin

• Synchronised cardioversion

Unstable
• Recurrent episode 

Longterm • medication: beta blocker, ca channel blocker,

amiodarone
• Radiofrequency ablation
Management Vagal Manuevers PEDIATRIC CARDIOLOGY UPDATE

1. Smaller children and infants

- Ice cold facecloth to the face
- Stimulate the vagal response

2. Older children
- carotid massage
- Valsalva technique
Chronic SVT Prevention PEDIATRIC CARDIOLOGY UPDATE

1. No treatment
2. Anti Arrhythmic drug
1. - iv amiodarone
2. - iv verapamil
3. - digoxin
3. Radiofrequency ablation
Summary PEDIATRIC CARDIOLOGY UPDATE

• 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

PEDIATRIC CARDIOLOGY UPDATE
 PEDIATRIC CARDIOLOGY UPDATE

Terima kasih
 PERWAKILAN V
MALANG

PEDIATRIC CARDIOLOGY UPDATE