Post on 13-Apr-2017
SupraventriculaSupraventricular Tachycardia in r Tachycardia in
PediatricPediatric
Cardiac arrhythmia
• is a abnormal electrical activity in the heart
• too fast or too slow
• regular or irregular.
DefinationDefination
OverviewOverview
Sinus tachycardiaSVTVFVTAtrial fibAtrial flutter
Sinus bradycardiaHeart block
Sinus arrhythmiaPACPVC
Tachycardia Bradycardia
Irregular
In structurally normal/ abnormal heartCongenital metabolic disorders of mitochondriaSLE
Rheumatic feverMyocarditisToxin (diphtheria)Pro-arrhythmic or anti-arrhythmic drugsSurgical correction of CHD
CongenitalCongenital AcquiredAcquired
Normal Heart Rate Normal Heart Rate Age Heart RateNewborn 120-160Infant 80- 140Toddler 1-3 yrs 80- 130Pre School 3-5yrs 80- 120School Age 6-12 yrs
70- 110
Adolescent 13+ 60- 100
Range from Completely asymptomatic Loss of consciousnessSudden cardiac death
In infantsLethargyPoor feedingIrritabilityCardiac failureUnderlying congenital
heart disease
In childrenPalpitationSyncopeDizzinessChronic fatigueShortness of breathChest discomfort
HistorySymptomsFrequency and length of episodeOnset and triggersAny underlying diseaseMedicationso Triggering factoro Used for underlying cardiac disease
Evaluation Child with Evaluation Child with ArrhythmiaArrhythmia
DiagnosisDiagnosisAlways do-12 Lead ECG!!!!!-During tachycardia-In sinus rhythm
Diagnostic methodsDiagnostic methods• Always• Always• Always record a rhythm
strip during any intervention (adenosine, cardioversion, Valsalva, etc.)
Diagnostic methodsDiagnostic methods• Holter• Event recorder• Exercise ECG• Post-op atrial/ventricular pacing wires• Esophageal pacing leads• Adenosine can be diagnostic• Invasive electrophysiology study
Sinus RhythmSinus RhythmEvery QRS complex is preceded by a P wave and every P wave must be followed by a QRS The P wave morphology and axis must be normal and PR interval will usually be normal for that age
Sinus ArrhythmiaSinus Arrhythmia
Most common irregularity of heart rhythm seen in childrenNormal variantHeart rate increases during inspiration and decreases during expiration
Sinus ArrhythmiaSinus Arrhythmia
Normal phasic variation of heart rate with respiration
Variable P-P intervals
No treatment needed
TachyarrhythmiaTachyarrhythmia
• Supraventricular Tachycardia• Ventricular Tachycardia
Basic Mechanism of Basic Mechanism of TachycardiaTachycardia
1.Re- entry – most common2.Automaticity3.Triggered activity - rare
Re – entry TachycardiaRe – entry Tachycardia
AutomaticityAutomaticity
SVTSVTMost common abnormal tachycardia seen in pediatric practiceMost common arrhythmia requiring treatment in pediatric populationMost frequent age presentation: 1st 3 months of life 2nd peaks @ 8-10 and in adolescence
SVTSVTCommonest mechanism – re-entry- Accessory pathway – 80%-AV nodal re-entry – 20%
-Younger age – accessory pathway-Older age - AVNRT
SVT - classificationSVT - classificationAV node Dependent Tachycardia
AV Node independent Tachycardia
AVRT - concealed pathway - manifest pathway -WPW syndrome
Sinus node reentrant Tachycardia
AVNRT - Typical ( slow-fast) - Atypical (Fast-slow)
Atrial Tachycardia - Focal atrial tachycardia - Multifocal atrial tachycardia
Juctional Ectopic Tachycardia ( JET)
Atrial Flutter
Permanent Juctional Reciprocating Tachycardia ( PJRT)
Atrial Fibrillation
P wave in TachycardiaP wave in Tachycardia- Important to identify p wave during the
tachycardia- Helps to guide types of SVT
- No p wave- Short RP tachycardia- Long RP tachycardia
P wave in TachycardiaP wave in TachycardiaNo visible p Wave, narrow complex- AVNRT
P wave in Tachycardia P wave in Tachycardia – Short RP– Short RP
- AVRT- Typical AVNRT
P wave in Tachycardia P wave in Tachycardia – Short RP– Short RP
P wave in Tachycardia P wave in Tachycardia – Long RP– Long RP
- Atypical AVNRT- PJRT- Atrial tachycardia- Sinus tachycardia- sinus node tachycardia
P wave in Tachycardia P wave in Tachycardia – Long RP– Long RP
What's Next?What's Next?LOOK FOR THE R-R interval
- regular- irregular
Gives clues on types of SVT
ANRT - P wave on ST ANRT - P wave on ST segmentsegment
Regular R-R intervalRegular R-R interval
AVNRT - p wave absent AVNRT - p wave absent or pseudo r wave on VI or pseudo r wave on VI
Regular R-R intervalRegular R-R interval
AET - Long RP AET - Long RP tachycardia with tachycardia with abnormal p wave abnormal p wave
morphology morphology Regular R-R intervalRegular R-R interval
PJRT -Long RP PJRT -Long RP tachycardia with tachycardia with abnormal p wave abnormal p wave
inverted lead II,III,aVF inverted lead II,III,aVF Regular R-R intervalRegular R-R interval
Atrial flutter – saw tooth Atrial flutter – saw tooth baselinebaseline
MET – Irregular MET – Irregular TachycardiaTachycardia
Long RPLong RPdifferent p wave different p wave
morphologymorphology
JET – Irregular R-R JET – Irregular R-R intervalinterval
p wave with VA p wave with VA dissociationdissociation
ManagementManagementTreatment Option SVT Termination
1.Vagal maneuvers2.Anti arrhythmic drugs ( IV or Oral )3.Electrical Termination
- DC cardioversion- Endocardial pacing- Trans Esophageal pacing
ManagementManagement
ManagementManagementVagal Maneuvers
1.Smaller childrens and infants- Ice cold facecloth to the face- Stimulate the vagal response
1.Older childrens- carotid massage- Valsalva technique
Management - IV Management - IV AdenosineAdenosine
• Diagnostic and therapeutic
• Given via central line better than peripheral
• Short half life
• 100-500mcg/kg given rapid IV push
• ALWAYS!!! Record rhythm strip during adenosine
Adenosine Response Adenosine Response
Adenosine responseAdenosine response
Adenosine ResponseAdenosine Response
SVT TreatmentSVT Treatment1. IV Verapamil – older childrens 0.1mg/kg
- Contraindicated in < 4 yrs old and in WPW syndrome
2. Digoxin – useful in infants- Contraindicated in WPW
3. IV propranolol 0.1mg/kg4. IV Flecanaide 0.5-2mg/kg5. IV amiodarone 5mg/kg in 30min and
5-15mcg/kg/min6. Cardioversion 0.5-2J/kg
Management- Management- PreventionPrevention
1.No treatment2.Anti Arrhythmic drug3.Radiofrequency ablation
Management - Management - PreventionPrevention
No Treatment
-Infrequent eposides-Explain -Educate on valsalva-PRN treatment in ED
Management - Management - PreventionPrevention
Management - Management - PreventionPrevention
Treatment OptionsTreatment Options1. AV node
- Digoxin- Class II – beta blockers- Class III – Amiodarone- Class IV – Verapamil
2. Accessory pathway- Class 1C – Flecanaide- Class III – Amiodarone- WPW- No Verapamil or Digoxin
Management - Management - PreventionPrevention
Radiofrequency Ablation
– invasive procedure- Curative -Older children's-Incessant SVT- PJRT-Symptomatic SVT-Drug refractory SVT-WPW with symptomatic
SummarySummary• SVT generally well tolerated, life threatening is
uncommon
• Record 12 lead ECG during arrhythmia
• Record rhythm strip during any intervention
• ECG clue for diagnosis – wide or narrow complex, p wave relationship to QRS and regular or irregular rhythm
• Proper diagnosis can guide appropriate Tx
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