PALS - Tachycardia 

Updated: Mar 21, 2014
  • Author: James J Lamberg, DO; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Pediatric Advanced Life Support (PALS): Tachycardia With Pulse

1. Initial evaluation [1, 2, 3]

  • Assess appropriateness for clinical condition
  • Heart rate typically ≥150 bpm in tachyarrhythmia

2. Initial intervention

  • Maintain patent airway
  • Assist breathing as needed
  • Administer oxygen if hypoxemic
  • Attach monitor/defibrillator
  • Monitor blood pressure and oximetry

3. Assess for signs of poor perfusion

  • Hypotension
  • Acutely altered mental status
  • Signs of shock

4. Therapeutic intervention for poor perfusion

  • If poor perfusion and QRS >0.09 seconds, perform immediate synchronized cardioversion
  • Consider sedation; do not delay therapy

5. Measures for adequate perfusion, QRS ≤0.09 seconds

  • Obtain intravenous (IV)/intraosseous (IO) access
  • Perform 12-lead electrocardiography (ECG), if available
  • Differentiate probable sinus tachycardia from supraventricular tachycardia (SVT)
  • SVT rate usually ≥180 bpm in children
  • SVT rate usually ≥220 bpm in infants
  • P waves normal in sinus tachycardia but absent or abnormal in SVT

6. If sinus tachycardia is most likely, treat underlying cause

7. Measures for probable SVT

  • Perform vagal maneuvers; do not delay therapy
  • Administer adenosine if IV/IO access
  • If no IV/IO or adenosine is ineffective, perform synchronized cardioversion

8. Measures for adequate perfusion, QRS >0.09 seconds

  • Obtain IV/IO access
  • If regular wide monomorphic, consider adenosine; do not delay therapy
  • Expert consultation advised
  • Consider amiodarone
  • Consider procainamide

Synchronized cardioversion

See the list below:

  • Begin with 0.5-1 J/kg and, if ineffective, increase to 2 J/kg
  • Sedate if needed; do not delay therapy

Drug therapy

See the list below:

  • Adenosine 0.1 mg/kg rapid IV/IO first dose; maximum dose, 6 mg
  • Adenosine 0.2 mg/kg rapid IV/IO second dose; maximum dose, 12 mg
  • Follow adenosine with IV flush
  • Amiodarone 5 mg/kg over 20-60 minutes
  • Procainamide 15 mg/kg over 30-60 minutes
  • Do not routinely administer amiodarone and procainamide together
  • Have equipment for transcutaneous pacing available when administering adenosine

Sedation therapy

See the list below:

  • Seek expert consultation (anesthesia), if available
  • Sedatives: diazepam, midazolam, etomidate, methohexital, propofol
  • Analgesics (consider in addition to sedation): fentanyl, morphine

Hypotension definitions

See the list below:

  • Term neonates (age 0-28 days): Systolic blood pressure (SBP) < 60 mm Hg
  • Infants (age 1-12 months): SBP < 70 mm Hg
  • Children aged 1-10 years: SBP < 70 + (age in years X 2)
  • Children older than 10 years: SBP < 90 mm Hg

Normal heart rate

See the list below:

  • Newborns to age 3 months: 85-205 bpm awake, 80-160 bpm asleep
  • Children aged 3 months to 2 years: 100-190 bpm awake, 75-160 bpm asleep
  • Children aged 2-10 years: 60-140 bpm awake, 60-90 bpm asleep
  • Children older than 10 years: 60-100 bpm awake, 50-90 bpm asleep

Normal respiratory rate

See the list below:

  • Infants: 30-60 respirations/min
  • Toddlers: 24-40 respirations/min
  • Preschool-aged children: 22-34 respirations/min
  • School-aged children: 18-30 respirations/min
  • Adolescents: 12-16 respirations/min