Pediatric Advanced Life Support (PALS): Tachycardia 

Updated: May 11, 2018
  • Author: James J Lamberg, DO; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Pediatric Advanced Life Support (PALS): Tachycardia With Pulse

PALS: Tachycardia

1. The initial evaluation is as follows: [1, 2, 3, 4]

  • Assess appropriateness for clinical condition (pulse present).
  • The heart rate is typically ≥150 bpm in tachyarrhythmia.

2. The initial intervention is as follows:

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

3. Assess for signs of poor perfusion, as follows:

  • Hypotension
  • Acutely altered mental status
  • Signs of shock

Tachycardia with Poor Perfusion

1. Evaluate QRS duration, as follows:

  • Determine if narrow (≤0.09 seconds) or wide (>0.09 seconds).
  • For narrow QRS complex tachycardia, obtain 12-lead electrocardiography (ECG) or monitor.

2. Measures for poor perfusion with QRS >0.09 seconds are as follows:

  • Possible ventricular tachycardia
  • Perform immediate synchronized cardioversion.

3. Measures for poor perfusion with QRS ≤0.09 seconds are as follows:

  • Obtain intravenous (IV)/intraosseous (IO) access.
  • 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
  • PR interval is constant in sinus tachycardia; heart rate is not variable in SVT.

4. If sinus tachycardia is most likely, search for and treat underlying cause.

5. Measures for probable SVT are as follows:

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

Tachycardia with Adequate Perfusion

1. Evaluate QRS duration: Determine if narrow (≤0.09 seconds) or wide (>0.09 seconds).

2. Measures for adequate perfusion with QRS >0.09 seconds are as follows:

  • Differentiate possible SVT (with QRS aberrancy) from probable ventricular tachycardia.
  • R-R interval regular and QRS morphology uniform in SVT

3. Measures for possible supraventricular tachycardia (QRS >0.09 seconds) are as follows:

  • Obtain intravenous (IV)/intraosseous (IO) access.
  • Consider adenosine.
  • If not improved, follow probable ventricular tachycardia with adequate perfusion algorithm below.

4. Measures for probable ventricular tachycardia with adequate perfusion are as follows:

  • Expert consultation strongly recommended
  • Search for and treat reversible causes.
  • Obtain 12-lead electrocardiography (ECG), if available.
  • Consider pharmacologic cardioversion (amiodarone or procainamide).
  • May attempt adenosine if not already administered
  • Consider electrical cardioversion, sedate before cardioversion, consult pediatric cardiologist.

5. Measures for adequate perfusion with QRS ≤0.09 seconds are as follows:

  • 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
  • PR interval is constant in sinus tachycardia; heart rate is not variable in SVT

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

7. Measures for probable SVT (QRS ≤0.09 seconds) are as follows:

  • Consider vagal maneuvers; do not delay therapy.
  • Obtain intravenous (IV)/intraosseous (IO) access.
  • Consider adenosine.
  • If not improved, follow probable ventricular tachycardia with adequate perfusion algorithm above.

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

Normal Heart Rate

See the list below:

  • Neonate: 100-205 bpm awake, 90-160 bpm asleep
  • Infants: 100-180 bpm awake, 90-160 bpm asleep
  • Toddlers: 98-140 bpm awake, 80-120 bpm asleep
  • Preschool-aged children: 80-120 bpm awake, 65-100 bpm asleep
  • School-aged children: 75-118 bpm awake, 58-90 bpm asleep
  • Adolescents: 60-100 bpm awake, 50-90 bpm asleep

Normal Respiratory Rate

See the list below:

  • Infants: 30-53 respirations/min
  • Toddlers: 22-37 respirations/min
  • Preschool-aged children: 20-28 respirations/min
  • School-aged children: 18-25 respirations/min
  • Adolescents: 12-20 respirations/min

Most Recent Guideline Changes

Changes from the 2010 guidelines include the following:

  • Simultaneous breathing and pulse check in less than 10 seconds
  • Administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm.
  • Provide opioid overdose education, either alone or coupled with naloxone distribution and training, to persons at risk for opioid overdose.

Changes from the 2010 PALS guidelines include the following:

  • Amiodarone or lidocaine is equally acceptable for the treatment of shock-refractory VT/VF in children.
  • There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric (age >1 year) intubations.
  • For septic shock, the initial fluid bolus is 20 mL/kg.
  • For children who are comatose in the first several days after cardiac arrest, fever should be treated aggressively.
  • For comatose children resuscitated from out-of-hospital cardiac arrest (OHCA), maintain either 5 days of normothermia or 2 days of initial continuous hypothermia (32˚C-34˚C) followed by 3 days of normothermia.