Frank P. Carnevale, M.D. Department of Pediatrics Division of Pediatric Emergency Medicine State University of New York at Buffalo November 13, 2013

 : Hypovolemic & Distributive Shock  : Cardiogenic & Obstructive Shock  : Tachycardia  : Bradycardia  : Fever Work-up  : ATLS & RSI Issues  : Cardiac Arrest  : Neonatal Resuscitation

 Differentiate SVT from ST  Recognize and manage pediatric tachycardia with a pulse and adequate vs. poor perfusion  Describe how and when to use vagal maneuvers, adenosine, and synchronized cardioversion for the treatment of SVT

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 Differentiate SVT from ST  Recognize and manage pediatric tachycardia with a pulse and adequate vs. poor perfusion  Describe how and when to use vagal maneuvers, adenosine, and synchronized cardioversion for the treatment of SVT

AgeAwake RateSleeping Rate 0 to 3 months85 to to months to 2 years100 to to to 10 years60 to to 90 > 10 years60 to to 90

 Tachycardia is a HR that is fast compared with the normal HR for the child’s age  Sinus Tachycardia is a normal response to stress or fever  Tachyarrhythmias are fast abnormal rhythms originating in the atria or ventricles  Tachyarrhythmias can be tolerated without symptoms for a variable amount of time  They can then cause acute hemodynamic compromise from shock to cardiac arrest

A. HR x BP B. BP x CVP C. MAP - ICP D. HR x SV E. SV x MAP 20

A. Mostly during systole B. Mostly during diastole C. About equally during systole and diastole D. Only during inspiration E. Only during expiration 20

 CO = HR x SV  Increase HR and you increase CO (to a point)  You reach a point when diastole is so short that the heart doesn’t have time to fill  When end-diastolic filling time decreases, SV decreases and therefore CO decreases  Also, coronary perfusion occurs during diastole, so this can be compromised  This, along with increased metabolic demand from tachycardia can lead to cardiogenic shock

A. 0.2 B C. 0.1 D E

A. > 0.09 sec B. > 0.07 sec C. > 0.12 sec D. < 0.1 sec E. < 0.2 sec 20

A. Sinus Tach B. SVT C. VT D. Atrial flutter E. A fib 20

Narrow Complex (< 0.09 second)Wide Complex (> 0.09 second) Sinus Tachycardia (ST)Ventricular Tachycardia (VT) Supraventricular tachycardia (SVT)SVT with aberrant intraventricular conduction Atrial Flutter

 A sinus node discharge rate faster than normal for a child’s age  Typically develops in response to body’s need for increased cardiac output  Common causes: exercise, pain, anxiety, tissue hypoxia, hypovolemia, shock, fever, metabolic stress, injury, toxins, and anemia

A. True B. False 20

A. True B. False 20

A. PR normal; R-R constant B. PR normal; R-R variable C. PR variable; R-R constant D. PR variable; R-R normal 20

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 An abnormally fast rhythm originating above the ventricles  Most commonly caused by a reentry mechanism that involves an accessory pathway  The most common tachyarrhythmia that causes cardiovascular compromise during infancy

 A rapid, regular rhythm that appears abruptly and may be episodic  In infants, often diagnosed when symptoms of CHF develop  Infants: irritability, poor feeding, rapid breathing, unusual sleepiness, vomiting, and pale, mottled, gray, or cyanotic skin  Older children: palpitations, SOB, chest pain, dizziness, light-headedness, syncope

A. Lack of beat-to- beat variability B. HR usually >240 C. P waves absent/abnormal D. R-R interval constant E. QRS <

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CharacteristicSTSVT HistoryGradual onset; Hx of pain, fever, dehydration, hemorrhage, etc. Abrupt onset/ termination/both; Infant- CHF; Child-palpitations Physical examSigns of underlying cause of ST (fever, hypovolemia) Signs of CHF Heart rateInfant: < 220 bpm Child: < 180 bpm Infant: > 220 bpm Child: > 180 bpm MonitorVariability in HR with changes in activity/stim. No variability ECGP waves present/normal/upright in I/aVF P waves absent/abnormal/inverted in II/III/aVF, following QRS Chest x-raySmall heart, clear lungsSigns of CHF (enlarged heart, pulm edema)

 Differentiate SVT from ST  Recognize and manage pediatric tachycardia with a pulse and adequate vs. poor perfusion  Describe how and when to use vagal maneuvers, adenosine, and synchronized cardioversion for the treatment of SVT

A. Fluids B. Antipyretics C. Search for and treat cause D. Propranolol E. Hyperventilation 20

A. Adenosine B. Cardioversion C. Defibrillation D. Amiodarone E. Vagal maneuvers 20

A. Defibrillation B. Vagal manuevers C. Procainamide D. Atropine E. Cardioversion 20

A. Defibrillation B. Epinephrine C. Amiodarone D. Cardioversion E. Adenosine 20

A. Defibrillation B. Cardioversion C. Amiodarone D. Vagal maneuvers E. Adenosine 20

PALS Tachycardia Algorithm. Copyright © American Heart Association

 Differentiate SVT from ST  Recognize and manage pediatric tachycardia with a pulse and adequate vs. poor perfusion  Describe how and when to use vagal maneuvers, adenosine, and synchronized cardioversion for the treatment of SVT

 The HR decreases when the vagus nerve is stimulated by slowing conduction through the AV node  If child stable, may repeat once  If child unstable, may try these while preparing for pharmacologic or electrical cardioversion  Infant: Bag of ice/water to the upper face for 15 seconds (don’t occlude nose or mouth)  Older child: Valsalva by blowing through an occluded or very narrow straw

 Drug of choice for treatment of SVT  Acts at AV node to block conduction for 10 sec  Common pitfall: drug administered too slowly or with and inadequate IV flush  2-syringe technique  A 10 sec period of asystole, brady, or 3 rd degree block may follow administration  1 st dose 0.1mg/kg (max 6 mg) IV/IO  2 nd dose 0.2mg/kg (max 12 mg) IV/IO

 Defibrillators can deliver unsynchronized and synchronized shocks  Unsynchronized: shock delivered any time during the cardiac cycle; used for defibrillation because there is no organized QRS  Synchronized: used for cardioversion from SVT and VT with a pulse; shock delivery is timed to coincide with the R wave of the QRS; goal is to prevent VF that results when you shock during the T wave

 Must select sync mode prior to EACH charge  If using paddles, must press both buttons simultaneously  When you press shock button, the unit may seem to pause before delivering shock (while waiting for capture)—keep holding down the buttons (if paddles) until shock delivered  If the R waves are low amplitude, may need to increase the gain or select a different ECG lead to achieve capture

 Differentiate SVT from ST  Recognize and manage pediatric tachycardia with a pulse and adequate vs. poor perfusion  Describe how and when to use vagal maneuvers, adenosine, and synchronized cardioversion for the treatment of SVT

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