Pediatric Tachycardia Treatment & Management

• Assess and stabilize airway, breathing, and circulation.
• Administer oxygen.
• Start intravenous (IV) fluids when indicated.
• Place a cardiorespiratory monitor.

Treatment depends on the condition of the patient and the etiology of the tachycardia.^[4] The child who appears ill with tachycardia requires rapid assessment for the presence of hypoxemia, shock, hypoglycemia, or life-threatening dysrhythmia.^[5]

• Assess and support airway and breathing as needed. Direct treatment of sinus tachycardia toward reversing the underlying medical condition.
• Supraventricular tachycardia

  • Asymptomatic patients or those with mild heart failure
    • Ice to face and vagal maneuvers: The diving reflex causes peripheral vasoconstriction and a vagally mediated decrease in cardiac output.
    • Adenosine: Dose for infants and children is 0.1 mg/kg (not to exceed 6 mg/dose) rapid IV push; if ineffective, the dose can be doubled to 0.2 mg/kg (not to exceed 12 mg/dose). Complications may include bronchospasm (relatively contraindicated in patients with asthma), bradycardia, headache, shortness of breath, dizziness, and nausea.
    • Propranolol: Usual dose for children is 1 mg/kg/dose PO q6h (may initiate at 1 mg/kg/day PO divided q6h, then titrate upward).
    • Digoxin: Total digitalizing dose (initial dosing) is 10 mcg/kg IV in infants, 20 mcg/kg IV in older children; administer 1/2 dose stat, then 1/4 dose q8-12h X 2 (contraindicated in WPW).
    • Procainamide: 15-50 mg/kg/d PO divided in 6 doses
  • Patients with moderate heart failure
    • Ice and vagal maneuvers
    • Adenosine IV (see above)
    • Amiodarone: 5 mg/kg IV over 20-60 min or procainamide 15 mg/kg IV over 30-60 min (do not routinely administer amiodarone and procainamide together)
    • Cardioversion, synchronized: 0.5-1 J/kg, doubling dose prn (up to 2 J/kg)
    • Propranolol: 0.01-0.1 mg/kg slow IV over 10 min
    • Digoxin IV (see above)
    • Rapid atrial pacing (esophageal or intracardiac)
  • Patients with severe heart failure
    • Cardioversion, synchronized - Initial dose 0.5-1 J/kg (see above)
    • Adenosine IV (see above)
    • Amiodarone IV or procainamide IV (see above)
    • Propranolol IV (see above)
    • Digoxin IV (see above)
    • Rapid atrial pacing (esophageal or intracardiac)
• Atrial fibrillation or flutter

  • For stable patients
    • Beta-blocker (eg, propranolol - 1 mg/kg/dose PO q6h)
    • Digoxin: Total digitalizing dose (initial dosing) is 10 mcg/kg IV in infants, 20 mcg/kg IV in older children; administer 1/2 dose stat, then 1/4 dose q8-12h X 2 (contraindicated in WPW).
    • Amiodarone: 5 mg/kg IV over 20-60 min
    • Cardioversion: 0.5-1 J/kg; may repeat prn up to a total dose of 2 J/kg. Administer cardioversion earlier if signs of severe cardiac failure manifest or if deterioration occurs during medical treatment. If patient is stable and presenting with >48 hours of signs of atrial dysrhythmia, consider anticoagulation prior to cardioversion.
  • For patients in shock
    • Immediate cardioversion: 0.5-1 J/kg; may repeat prn up to a total dose of 2 J/kg.
• Ventricular tachycardia^[6]

  • For stable patients, consider the following medications in consultation with a pediatric cardiologist:
    • Amiodarone: 5 mg/kg IV over 20-60 min or procainamide 15 mg/kg IV over 30-60 min (do not routinely administer amiodarone and procainamide together)
    • Cardioversion: 0.5 J/kg; may increase to 1 J/kg, then 2 J/kg if initial dose ineffective. Administer cardioversion earlier if signs of severe cardiac failure manifest or if deterioration occurs during medical treatment.
  • Patients in shock and those with pulseless VT or ventricular fibrillation
    • Assess ABCs and secure IV access.
    • Start cardiopulmonary resuscitation (CPR) and ventilate with 100% oxygen (Do not delay defibrillation with these interventions).
    • Defibrillate once with 2 J/kg. May use AED for children aged >1 year. Use the pediatric AED system, if available, for children aged 1-8 years.
    • Give 5 cycles of CPR.
    • Check rhythm and if shockable, defibrillate once with 4 J/kg.
    • Resume CPR immediately.
    • Administer epinephrine 0.01 mg/kg (1:10,000: 0.1 mL/kg) IV/IO or if via endotracheal tube (ET) 0.1 mg/kg (1:1000: 0.1 mL/kg). Repeat epinephrine q3-5min.^[7]
    • Give 5 cycles of CPR.
    • Check rhythm and if shockable, defibrillate once with 4 J/kg.
    • Consider lidocaine 1 mg/kg IV/IO/ET bolus.
    • Consider amiodarone 5 mg/kg IV/IO.
    • Consider magnesium 25-50 mg/kg IV/IO.
    • If rhythm is nonshockable, resume CPR immediately and administer epinephrine as stated above.

Consult a cardiologist for all cases of true dysrhythmia, particularly if the patient is unstable.