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APLS > The child with an abnormal pulse rate or rhythm > Flashcards

The child with an abnormal pulse rate or rhythm Flashcards

1
Q

Are tachyarrhythmias and bradyarrhythmias in children usually regular or irregular?

A
  • Tachyarrhythmias = REGULAR
  • BRadyarrhyhtmias = IRREGULAR
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2
Q

Name some of the causes of tachy- and brady-arrhythmias in children.

A

VITAMIN C+D

  • Tachyarrhythmias
    • vascular: myocarditis, cardiomyopathy, long QT syndrome, other channelopathies e.g. catecholaminergic polymorphic VT
    • metabolic: disturbance, hyperkalaemia
    • iatrogenic: after cardiac surgery
    • congenital: re-entrant congenital conduction pathway anomaly
    • drugs: poisoning e.g. tri-cyclic anti-depressants, quinidine (both), procainamide (VT), quinine, disopyramide, amiodarone digoxin (torsades de pointes)
  • Bradyarrhythmias
    • vascular: long QT syndrome, raised ICP, PRE-TERMINAL in hypoxia/ shock/ ischaemia
    • iatrogenic: conduction pathway damage following cardiac surgery, vagal stimulation during intubation/ suctioning
    • congenital: heart block (rare), incidental in sporty & athletic children
    • drugs: poisoning e.g. b-blockers, digoxin
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3
Q

How do arrhythmias present in the pre-verbal and verbal child?

A
  • Pre-verbal = poor feeding
  • Verbal = palpitations
  • Both: heart failure, shock
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4
Q

Describe the primary assessment & resuscitation of children with abnormal rate/ rhythm.

A
  • A
    • airway opening manoeuvres
    • adjuncts
    • I+V
  • B
    • high flow O2 with non rebreather mask
    • BVM –> consider I+V
      • hypoventilating
      • bradycardia
  • C
    • HR
      • likely tachyarrhythmia if: (ECG If:)
        • > 220 infants (>200)
        • > 180 children (>150)
      • bradycardia
        • < 60 bpm or
        • rapidly falling + poor perfusion
    • ECG
      • rate
      • rhythm: regular or irregular?
      • p-waves
      • QRS complex: broad or narrow?
        • narrow (+ absent p-wave) = SVT
        • wide = VT (hyperK+, TCA poisoning)
    • Bloods - baseline + U+E/ glucose

Emergency Mx:

  • Bradycardia (+ shock)
    • 100% O2 +/- BVM / I+V
    • chest compressions
    • 20 ml/ kg bolus
    • atropine IV/ IO
      • ​if vagal overactivity
      • 20 mcg/ kg
      • min. 100 mcg - max 600 mcg
      • can repeat up to 1mg child/ 2mg adolescent
    • adrenaline (if bolus ineffective)
      • ​10 mcg/ kg
      • –> ineffective
      • –> infusion 0.05 - 2 micrograms/kg/min
    • ? poisoning - TOXBASE
  • VT (+ shock)
    • P on AVPU –> anaesthetise + sedate
    • synchronised DC cardioversion
    • 2 J/kg –> repeat +/- increase
    • or asynchronised if not possible (otherwise may deteriorate to VF/ asystole)
  • SVT
    • ​continuous ECG monitoring + paper recording
    • Vagal manoeuvre (increas vagal tone, slow AV conduction)
      • diving reflex (iced water glove or immerse the face for 5 secs)
      • carotid sinus massage (1 side only!)
      • Valsalva (blow through a straw)
    • ADENOSINE
      • IV/ IO (antecubital fossa - large vein, proximity to heart)
      • 100 mcg/ kg –> 200 –> 300
      • 2 mins apart
      • (max single dose 500 mcg/kg or 300 mcg/kg if < 1 month)
      • half life 10 secs - may need to rpt
      • (max total 12 mg)
    • Synchronous DC shock
      • preferable when the child is SHOCKED (shock for shock)
      • 1 - 2 - 2 J / kg
      • if using then only use 1 x drug
    • Other anti-arrhythmics - call CATS/ Cardiologist
      • Amiodarone
        • ​refractory atrial tachy
      • Propranolol (PO/ IV)
        • ​IV may cause asystole
        • NOT if on verapamil
        • by mouth or IV
      • Flecainide
        • ​membrane stabiliser
      • Verapamil
        • ​not in < 1 year
        • irreversible hypotension + asystole
        • NOT if on b-blockers e.g. propranolol/ flecainide/ amiodarone
      • Digoxin
        • only on advice of cardiology
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5
Q

What is the most common cause of bradycardia in children?

A

PRE-TERMINAL!

RESP/ CIRCULATORY INSUFFICIENCY

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6
Q

Describe the emergency Mx of bradycardia

A

BRADYCARDIA

  • B
    • 100% O2 +/- BVM / I+V
  • C
    • chest compressions
    • 20 ml/ kg bolus
    • atropine IV/ IO
      • ​if vagal overactivity
      • 20 mcg/ kg
      • min. 100 mcg - max 600 mcg
      • can repeat up to 1mg child/ 2mg adolescent (total)
    • adrenaline (if bolus ineffective)
      • ​10 mcg/ kg
      • –> ineffective
      • –> infusion 0.05 - 2 micrograms/kg/min
    • ? poisoning - TOXBASE
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7
Q

What is the most common non-arrest arrhythmia during childhood & the most common arrhythmia causing CV instability in infancy?

A

SVT

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8
Q

What HR does SVT usually cause?

A

> 220 infants (often 250-300)

>180 children

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9
Q

How can you distinguish between sinus tachycardia and SVT?

A
  • HR
    • bpm
      • sinus < 200
      • SVT infants > 220
    • beat to beat variability
        • = sinus (& responsive to stimulation)
        • = SVT
    • termination (in response to treatment)
      • abrupt = SVT
      • Gradual = sinus
  • p-waves
    • difficult to identify in either case when HR > 200
    • absent in SVT
    • upright in I + AVF in sinus
    • negative in II + III + AVF in SVT
  • History
    • shock e.g. GE/ Sepsis = usually sinus tachy.
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10
Q

What symptoms might verbal children experiencing SVT complain of?

A
  1. light headedness/ dizziness
  2. chest discomfort
  3. palpitations
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11
Q

Why does deterioration of cardiac function occur in SVT?

A
  • very fast heart rate
  • very short diastolic phase
  • coronary arteries can only supply heart muscle with oxygen and nutrients during this phase
  • –> low CO state
  • –> shock
  • (occurs faster in children where myocardial function already impaired e.g. cardiomyopathy
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12
Q

Describe the emergency Mx of SVT.

A

SVT

  • ​continuous ECG monitoring + paper recording
  • Vagal manoeuvre (increas vagal tone, slow AV conduction)
    • diving reflex (iced water glove or immerse the face for 5 secs)
    • carotid sinus massage (1 side only!)
    • Valsalva (blow through a straw)
  • ADENOSINE
    • IV/ IO (antecubital fossa - large vein, proximity to heart)
    • 100 mcg/ kg –> 200 –> 300
    • 2 mins apart
    • (max single dose 500 mcg/kg or 300 mcg/kg if < 1 month)
    • half life 10 secs - may need to rpt
    • (max total 12 mg)
  • Synchronous DC shock
    • preferable when the child is SHOCKED (shock for shock)
    • 1 - 2 - 2 J / kg
    • if using then only use 1 x drug
  • Other anti-arrhythmics - call CATS/ Cardiologist - F! PAVED (the way to health)
    • Flecainide
      • ​membrane stabiliser
    • Propranolol (PO/ IV)
      • ​IV may cause asystole
      • NOT if on verapamil
    • Amiodarone
      • ​refractory atrial tachy
    • VErapamil
      • ​not in < 1 year
      • irreversible hypotension + asystole
      • NOT if on b-blockers e.g. propranolol/ flecainide/ amiodarone
    • Digoxin
      • only on advice of cardiology
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13
Q

What are the side effects of adenosine treatment in SVT?

A
  1. flushing
  2. nausea
  3. DIB/ chest tightness

Usually short lives (half life 10 secs).

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14
Q

Whats is torsades de pointes?

What is it caused by?

A

Polymorphic VT.

QRS complexes change in amplitude + polarity,

they seem to rotate around an isoelectric line.

May be caused by:

  • long QT interval
  • poisoning e.g. TCAs, quinidine, quinine, isopyramide, amiodarone, digoxin
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15
Q

Name some of the causes of VT.

A

VT

  • Vascular: cardiomyopathy, myocarditis, long QT syndrome, other channelopathies e.g. catecholaminergic polymorphic VT
  • Metabolic: HyperK+
  • Iatrogenic: after cardiac surgery
  • Congenital: heart disease
  • Drugs: poisoning with TCAs, quinidine (both), procainamide (VT), digoxin, amiodarone, quinidine, disopyramide (torsades de pointes)
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16
Q

What Ix should be done in VT?

A
  1. Cardiac monitoring + ECG ? torsades de pointes
    • NB d/w paeds cardio
  2. Bloods - baseline + electrolytes incl. K, Ca, Mg
17
Q

Describe the emergency Mx of VT.

A

STABLE or UNSTABLE VT? TORSADES?

  • STABLE / no shock
    • ECG –> d/w cardio urgently
    • Bloods incl. K/ Mg/ Ca
    • Mx – on advice of cardio: be PR-A-VE
      • PRocainamide
        • NB hypotension / give bolus
        • 15 mg/kg over 30-60 mins
      • Amiodarone
        • NB hypotension / give bolus
        • 5 mg/ kg over 20-30 (neonates) mins
      • VErapamil
        • rare types may respond
  • UNSTABLE / shock
    • no pulse –> VF protocol
    • anaesthesia / sedation (I+V) first if conscious/ responding to pain!!
    • synchronised DC cardioversion
      • 2 - 4 - 4 J/ Kg
      • (double that of SVT)
      • synchronised - less likely to produce VF
      • if ineffectual + in shock try asynchronised
      • safest approach in drug toxicity
  • Torsades de pointes?
    • DC cardioversion +
    • IV MgSO4 25-50 mg/kg
      • (max 2g)
    • +/-
      • lidocaine
      • IV b-blocker
  • WARNING
    • do NOT delay treatment in VT
    • often quickly deteriorates to pulseless VT/ VF
    • if uncertain whether SVT w/ bundle branch block (=> wide complex) or VT, treat as VT
      • Can trial 1x adenosine in stable children
      • may cause worse tachycardia + hypotension

APLS (25 decks)

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