1. Arrhythmias

2. ECG
ECG is a graphic representation of the sequence of myocardial depolarisation and repolarisation. Each noarmal cardiac cycle consists of a
P wave
QRS complex
T wave

3. Anatomy of the conduction system in relation to ECG

4. Normal Heart Rate by Age

5. Placement of electrodes for ECG Monitoring

6. Cardiac Rhythm Disturbances
Recognize that rhythm disturbances are an uncommon cause of cardiovascular arrest in children
Define 3 classes of rhythm disturbances
Assess and manage rhythm disturbances associated with shock (unstable)

7. Treatment - Stable Versus Unstable
Unstable rhythms require emergency therapy
Rhythms that cause circulatory instability
Rhythms that may deteriorate and cause circulatory instability

8. Assessment of Cardiovascular Function
Assess Ventilation, Heart rate, Peripheral pulses, End organ perfusion, Blood pressure.
Is CPR needed?
Is cardiovascular instability present?
Compensated shock
Hypotensive shock
Cardiopulmonary arrest

9. Definition of Rhythm Groups by Pulse (central) Rate Fast pulse = Tachyarrhythmia Slow pulse = Bradyarrhythmia Absent pulse = Collapse rhythms
Rate
Infant
Child
Fast
>220
>180
Slow
<80
<60

10. Development of Shock From Pulse Rate Disturbances Cardiac Output = Heart Rate X Stroke VolumeHR X SV
FAST
Low
High
SLOW
Normal , High or Low
ABSENT

11. Assessment of Cardiac Rhythm Group
Is the pulse rate slow, fast or absent?
Is the perfusion compromised?
Are the ventricular complexes wide or narrow?
Is there a diagnostic pattern to the ECG?

12. Assessment Of Tachycardia ( Fast Pulse )
Tachycardia appropriate for clinical condition= Sinus tachycardia
Tachycardia excessive for clinical condition= Tachyarrhythmia
Narrow QRS Complex
Sinus Tachycardia
Supraventricular Tachycardia
Wide QRS Complex
Ventricular Tachycardia

13. Supraventricular Tachycardia
Sinus Tachycardia
Supraventricular Tachycardia
History
Possible history of fever, pain, or volume loss (eg. Diarrhea, vomiting, bleeding)
Nonspecific history of irritability, lethargy, poor feeding, tachypnea, sweating, pallor, or hypothermia
Heart Rate
P waves present and normal
Variable RR with constant PR
Infants rate <220bpm
Children <180bpm
P waves absent or abnormal
Abrupt rate change to or from normal
Infants rate usually>220bpm
Children >180bpm

14. Sinus Rhythm

15. Supraventricular Tachycardia

16. Ventricular Tachycardia

19. SUMMARY - FAST RATE Etiology Treatment Narrow QRS (Probable SVT)
Vagal Maneuver
Adenosine (if IV access)
Synchronized Cardio version
Wide QRS
(Probable VT)
Amiodarone / Lidocaine / Procaineamide / Magnesium Sulphate

20. Drug Treatment of SVT- Adenosine
0.1 to 0.2 mg/kg
Maximum single dose:12 mg

21. Bradyarrhythmia

22. Etiology of Bradycardia
Hypoxia
Hypothermia
Head injury
Heart Block
Heart Transplant
Toxins/poisons/drugs

23. What Is the Rhythm?
BRADYCARDIA

24. Management of Bradycardia
Oxygenation (FiO2 = 1.00) and ventilation
Chest Compressions
Epinephrine
Dose: IO/IV, ml /kg of 1:10000
ET, 0.1 ml /kg of 1:1000
Atropine
Dose : IO/IV: 0.02 mg/kg, Minimum 0.1 mg
Maximum Single Dose (may repeat once)
Child: 0.5mg, Adolescent: 1 mg
?? Pacing

25. Treat potential reversible causes of Bradycardia

28. Case Study
8 year old submersion victim with
Apnea
No palpable pulses
What Arrhythmias could be present?

29. Absent Pulse
Asystole
Ventricular fibrillation
Pulseless ventricular tachycardia
Pulseless electrical activity / electromechanical dissociation

30. ASYSTOLE

31. Absent Pulse (Collapse Rhythms)-Asystole Treatment
CPR
Secure airway
Ventilate with 100% oxygen
Obtain IV or IO access
Epinephrine q 3-5 min

32. VENTRICULAR FIBRILLATION

34. Defibrillation - updates
First dose – 2 J / kg
Second & subsequent dose – 4 J / kg
Superiority & greater safety of biphasic over monophasic shocks & less energy requirement
Drug administration during CPR
Minimum interruptions in Chest Compressions

35. Defibrillation

36. starting with chest compression needed in all 3 post shock situations
High quality CPR
starting with chest compression needed in all 3 post shock situations

37. Case Study
A 2 year old child was struck by an automobile
Respiratory rate = 0
Central pulse = absent

38. What are the priorities for treatment?
PULSELESS ELECTRICAL ACTIVITY
Rhythm 60 beats/min
What are the priorities for treatment?

39. Treat Cause

40. SUMMARY: Rx by Pulse Rate in a Child with Shock
TREATMENT
FAST
Synchronized Cardioversion
Adenosine (in SVT if IV access +)
SLOW
Ventilation, oxygenation, compressions, epinephrine
ABSENT
CPR (beginning with chest compressions)
VF/VT: immediate defibrillation
PEA/EMD: Identify and treat the cause
Epinephrine

41. Questions to answer in order to identify an unknown arrhythmia: :
Is the rate slow (<60 bpm) or fast (>100 bpm)?
Slow - Suggests sinus bradycardia, sinus arrest, or conduction block
Fast -Suggest increased/abnormal automaticity or reentry
Is the rhythm irregular?
Irregular -Suggests atrial fibrillation, 2nd degree AV block, Multifocal atrial tachycardia, or atrial flutter with variable AV block
Is the QRS complex narrow or wide?
Narrow - Rhythm must originate from the AV node or above
Wide - Rhythm may originate from anywhere

42. Questions to answer in order to identify an unknown arrhythmia: :
4. Are there P waves? Absent P waves - Suggests atrial fibrillation, ventricular tachycardia, or rhythms originating from the AV node 5. What is the relationship between the P waves and QRS complexes? More P waves than QRS complexes - Suggests 2nd or 3rd degree AV block More QRS complexes than P waves - Suggests an accelerated junctional or ventricular rhythm 6. Is the onset/termination of the rhythm abrupt or gradual? Abrupt - Suggests reentrant rhythm Gradual - Suggests altered automaticity

43. Treat The Patient Not The Rhythm