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.