Pediatric Tachycardia Clinical Presentation

  • Author: Mirna M Farah, MD; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Apr 16, 2012
 

History

  • Chest pain
  • Palpitations
  • Syncope
  • Dizziness
  • Shortness of breath
  • Diaphoresis (for infants—while feeding)
  • Color changes
  • Neurologic changes (mental status, motor/sensory deficits)
  • Decrease in intake and output
  • Trauma
  • Pain
  • Fever
  • Onset/duration of illness
  • Relationship to exercise, meals, and stress
  • Medical history, especially history of tachycardia or other cardiac problems
  • Medications - Amphetamines, cocaine, caffeine, ephedrine, antihistamines, phenothiazines, antidepressants, theophylline, appetite suppressants, albuterol
  • Allergies
  • Family history of sudden death, deafness (Jervell-Lange Nielsen syndrome) or cardiac disease
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Physical

  • General appearance
  • Temperature
  • Heart rate
  • Respiratory rate
  • Blood pressure
  • Oxygen saturation
  • Assessment of pain
  • Decreased level of consciousness, decreased level of activity
  • Jugular venous distention
  • Neck mass
  • Dyspnea, increased work of breathing, retractions
  • Crackles, wheezing
  • Cardiac gallop
  • Cardiac murmur
  • Increased liver size
  • Abdominal mass
  • Decreased urine output
  • Poor peripheral perfusion (delayed capillary refill >2 sec, cool extremities, pallor)
  • Cyanosis
  • Edema
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Causes

Tachycardia can be due to a physiologic response of the heart to noncardiac stimuli or to a true dysrhythmia.[3, 4]

  • Hyperdynamic cardiac activity
    • Increased heart rate and contractility are physiologic responses to catecholamine release.
    • Catecholamine release may occur with stress or anxiety, exercise, fever or infection, pain, anemia, seizure, hypovolemia, hypoxia, drugs or medications/stimulants (eg, amphetamines, cocaine, caffeine, ephedrine, antihistamines, phenothiazines, antidepressants, tobacco, theophylline, general anesthesia), vasodilation (eg, anaphylaxis), oncologic mass (pheochromocytoma, neuroblastoma), hypoglycemia, hyperthyroidism, or acidosis.
  • True dysrhythmias
    • Supraventricular tachycardia (SVT)
    • Atrial fibrillation or atrial flutter
      • Drug induced
      • Wolff-Parkinson-White syndrome (WPW)
      • Postoperative cardiac repair
      • Congenital or rheumatic mitral disease
      • Hyperthyroidism
    • Junctional ectopic tachycardia (JET) - Postoperative cardiac repair
    • Ventricular tachycardia (VT)
      • Drug induced (eg, tricyclics, phenothiazines, antiarrhythmics, chloral hydrate, organophosphates, hydrocarbons, digoxin, amphetamines, cocaine, arsenic)
      • Prolonged Q-T syndrome/torsades de pointes
      • Myocarditis
      • Rheumatic fever
      • Mitral valve prolapse
      • Cardiomyopathy
      • Myocardial ischemia
      • Postoperative cardiac repair
      • Hyperkalemia (peaked T waves, prolonged QRS and QT intervals)
      • Hypocalcemia (increased QT intervals secondary to ST-segment prolongation)
      • Hypokalemia (especially in association with digoxin use due to its synergistic effects on automaticity and conduction)
      • Hypomagnesemia (associated with hypocalcemia and hypokalemia)
      • Cardiac tumors
      • Arrhythmogenic right ventricular dysplasia
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Contributor Information and Disclosures
Author

Mirna M Farah, MD  Associate Professor of Pediatrics, University of Pennsylvania School of Medicine; Attending Physician, Division of Emergency Medicine, Children's Hospital of Philadelphia

Mirna M Farah, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

Christine S Cho, MD, MPH  Assistant Professor, Departments of Pediatrics and Emergency Medicine, University of California, San Francisco, School of Medicine

Christine S Cho, MD, MPH is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

David A Peak, MD  Assistant Residency Director of Harvard Affiliated Emergency Medicine Residency, Attending Physician, Massachusetts General Hospital; Consulting Staff, Department of Hyperbaric Medicine, Massachusetts Eye and Ear Infirmary

David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Grace M Young, MD  Associate Professor, Department of Pediatrics, University of Maryland Medical Center

Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD  Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston

Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research

Disclosure: Nothing to disclose.

References

  1. Custer JW, Rau RE, eds. Johns Hopkins: The Harriet Lane Handbook. 18th ed. Philadelphia, PA: Mosby Elsevier Inc; 2008.

  2. Song MK, Baek JS, Kwon BS, Kim GB, Bae EJ, Noh CI, et al. Clinical spectrum and prognostic factors of pediatric ventricular tachycardia. Circ J. Sep 2010;74(9):1951-8. [Medline].

  3. Wiley JF. Tachycardia/palpitations. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 5th ed. 2006:657-668.

  4. Kaltman J, Shah M. Evaluation of the child with an arrhythmia. Pediatr Clin North Am. Dec 2004;51(6):1537-51, viii. [Medline].

  5. [Guideline] 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 12: Pediatric Advanced Life Support. Circulation. 2005;112(24 Suppl):IV167-87. [Full Text].

  6. Gewitz MH, Woolf PK. Cardiac emergencies. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 5th ed. 2006:717-758.

  7. Chang PM, Silka MJ, Moromisato DY, Bar-Cohen Y. Amiodarone versus procainamide for the acute treatment of recurrent supraventricular tachycardia in pediatric patients. Circ Arrhythm Electrophysiol. Apr 2010;3(2):134-40. [Medline].

  8. Samson RA, Atkins DL. Tachyarrhythmias and defibrillation. Pediatr Clin North Am. Aug 2008;55(4):887-907, x. [Medline].

  9. Perondi MB, Reis AG, Paiva EF, et al. A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest. N Engl J Med. Apr 22 2004;350(17):1722-30. [Medline].

  10. Physicians' Desk Reference. 63rd ed. Thomson Healthcare; 2009.

 
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This ECG belongs to an asymptomatic 17-year-old male who was incidentally discovered to have Wolff-Parkinson-White (WPW) pattern. It shows sinus rhythm with evident preexcitation. To locate the accessory pathway (AP), the initial 40 milliseconds of the QRS (delta wave) are evaluated. Note that the delta wave is positive in lead I and aVL, negative in III and aVF, isoelectric in V1, and positive in the rest of the precordial leads. Therefore, this is likely a posteroseptal AP.
This is a 12-lead ECG from an asymptomatic 7-year-old boy with Wolff-Parkinson-White (WPW) pattern. Delta waves are positive in leads I and aVL; negative in II, III, and aVF; isoelectric in V1; and positive in the rest of the precordial leads. This again predicts a posteroseptal location for the accessory pathway (AP).
 
 
 
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