PALS: TACHYDYSRHYTHMIAS AND WPW

Question 1

3 Questions to Ask for which Algorithm to Use

Answer 1

Is a pulse present?

Is perfusion adequate?

Is the QRS complex normal/narrow or wide? (narrow complex QRS (≤ 0.09 sec) or wide complex QRS (>0.09)?

Question 2

Approach to the Critically Ill Narrow Complex Tachycardia

Answer 2

CIRCULATION:

Monitor
Oxygen
Vitals
IV Access
ECG & Equipment

Defibrillator / Pacer Pads On

Assess for Pulse

Assess QRS Duration:
< 0.09 sec

Assess for Stability:
Hypotension
AMS
Signs of shock

POCUS IVC for volume status

UNSTABLE OR FAILED DRUG THERAPY:
Synchronized cardioversion 0.5 - 1 J / kg, increase to 2 J / kg

STABLE NARROW COMPLEX TACHYCARDIA:
Compatible history
P waves absent / abnormal
HR NOT variable
Infant > 220
Child > 180

Vagal maneuvers

Adenosine IV / IO: 0.1 mg / kg (max 6 mg) -> 0.2 mg / kg (max 12 mg)

Procainamide: 15 mg / kg IV over 30 - 60 min until 50% QRS widening

Question 3

Approach to the Critically Ill Wide Complex Tachycardia

Answer 3

CIRCULATION:

Monitor
Oxygen
Vitals
IV Access
ECG & Equipment

Defibrillator / Pacer Pads On

Assess for Pulse

Assess QRS Duration:
> 0.09 sec

Assess for Stability:
Hypotension
AMS
Signs of shock

POCUS IVC for volume status

MANAGEMENT:

DO NOT USE NODAL BLOCKING AGENTS INCLUDING BETA BLOCKERS OR CCB’S

Synchronized cardioversion 0.5 - 1 J / kg, increase to 2 J / kg

Procainamide: 15 mg / kg IV over 30 - 60 min until 50% QRS widening

OR

Amiodarone: 5 mg / kg over 30-60 min

Question 4

DDx: Tachycardia

Answer 4

Sinus tachycardia
Supraventricular tachycardia
Atrial flutter
Ventricular tachycardia
Wide-complex QRS tachycardia

Question 5

DDx: Etiology of Sinus Tachycardia

Answer 5

anemia
anxiety
fever
injury
hypoxia
hypovolemia
toxins/drugs

Question 6

SVT Heart Rate in Infants Vs. Childres

Answer 6

Infants:
> 220 beats per minute.
Children:
>180 beats per minute.

Question 7

MCC SVT

Answer 7

reentrant SVT

Question 8

Signs of Hemodynamic Instability in children

Answer 8

Shortness of breath
Palpitation feeling in chest
Ongoing chest pain
Dizziness
Rapid breathing
Altered or complete loss of consciousness
Capillary refill > 2 sec.
Hypotension
JVD
Other signs of shock

Question 9

Signs of Hemodynamic Instability in infants

Answer 9

poor feeding
irritability
tachypnea

Question 10

Approach to the Critically Ill Atrial Fibrillation with Accessory Pathway: Narrow and Wide Irregular Rhythm

Answer 10

CIRCULATION:

Monitor
Oxygen
Vitals
IV Access
ECG & Equipment

Defibrillator / Pacer Pads On

Assess for Pulse

Assess QRS Duration:
Variable

Assess for Stability:
Hypotension
AMS
Signs of shock

POCUS IVC for volume status

MANAGEMENT:

DO NOT USE NODAL BLOCKING AGENTS INCLUDING BETA BLOCKERS OR CCB’S

Synchronized cardioversion 0.5 - 1 J / kg, increase to 2 J / kg

Procainamide: 15 mg / kg IV over 30 - 60 min until 50% QRS widening or hypotension develops

OR

Amiodarone: 5 mg / kg over 30-60 min

Question 11

Wolf-Parkinson-White: CRITERIA

Answer 11

Wolf-Parkinson-White: CRITERIA:

Triad of:

PR Interval <120 msec

Delta Wave (Initial Slurring of the QRS ) in at least 2/3 orthogonal leads (I, aVF, V2)

Prolonged QRS complex >110 msec

a/w:

Discordant ST and T Changes (inverted T Waves) in opposite direction of the QRS complex