Pediatric Tachycardia Treatment & Management

  • Author: Mirna M Farah, MD; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Sep 23, 2009
 

Prehospital Care

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

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.
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Consultations

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

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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  Attending Physician, Division of Emergency Medicine, Children's Hospital and Research Center of Oakland; HS Assistant Clinical Professor, Department of Pediatrics, 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. Wiley JF. Tachycardia/palpitations. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 5th ed. 2006:657-668.

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

  4. [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].

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

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

  7. 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].

  8. 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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