Dysrhythmias, Drugs, Drips, and Defibrillation

Pediatric ConsiderationsTerri M. Repasky MSN, RN, CEN, EMT-PClinical Nurse Specialist - Emergency

Dysrhythmias

• Rhythm disturbances are an uncommon cause of cardiovascular arrest in children

• In pediatrics we use three classes of rhythms

Rhythm group by pulse rate

• Slow pulse = bradyarrythmia

• Fast pulse = tachyarrhythmia

• Absent pulse = collapse rhythms

Slow Pulse

Fast Narrow Pulse

Fast Wide Pulse

NO Pulse

Things to Consider

• Is the patient stable or unstable ?

• Is the patient’s condition causing the rhythmOR is the rhythm causing the condition?

• Is the rhythm causing the patient to be unstable ?

Assessment of Cardiovascular Function

• Ventilation and Oxygenation

• Heart Rate

• End-organ perfusion

• Peripheral pulses

• Skin signs

• LOC

• Blood pressure

Pulses Blood Pressure

• Compensated Shock

• Hypotensive Shock

Blood Pressure

Cardiac Output = Heart Rate x Stroke Volume

Back to Pulses

• Is it fast, slow, or absent?• Is perfusion compromised?• Are the ventricular complexes wide or

narrow?• Is there a diagnostic pattern to the EKG?

Sinus Tachycardia

Supraventricular Tachycardia

Fast Pulse Narrow Ventricular Complex

• Sinus Tachycardia• Supraventricular Tachycardia

Fast Pulse Narrow Ventricular Complex

• Sinus Tachycardia

• Possible history of fever, pain, volume loss (diarrhea, vomiting, bleeding, trauma), anxiety, meds

• Supraventricular Tachycardia

• Nonspecific history of irritability, lethargy, poor feeding, tachypnea, sweating, pallor or hypothermia

Fast Pulse

• Tachycardia appropriate for the clinical condition

• Tachycardia excessive for the clinical condition

Fast Pulse

• Tachycardia appropriate for the clinical condition

• Sinus Tachycardia (ST)

• Tachycardia excessive for the clinical condition

• SupraVentricular Tachycardia (SVT)

Fast Pulse Narrow Ventricular Complex (QRS)

• Is it Supraventricular Tachycardia (SVT) or

• Sinus Tachycardia (ST) ???

Fast Pulse Narrow Ventricular Complex (QRS)

• Is it Supraventricular Tachycardia (SVT) or

• Sinus Tachycardia (ST) ???

History and Heart Rate are big clues

Fast Pulse Narrow Ventricular Complex

Heart Rate Probable SVT> 180 Children> 220 Infants

Fast Pulse Tachycardia excessive for the clinical condition

(not Sinus Tach)

Stable, Perfusing Patient

• Narrow QRS (probable SVT)

• Wide QRS (probable VT)

• Vagal Maneuvers• Adenosine• Expert Consultation• Amiodarone or

Procainamide• Treat possible contributing factors

• Expert Consult• Amiodarone or

Procainamide• Treat possible contributing factors

Fast Pulse Tachycardia excessive for the clinical condition

Unstable Patient, Poor Perfusion

• Narrow QRS (probable SVT)

• Wide QRS (probable VT)

• Synchronized Cardioversion• (may try Adenosine if it does not delay electrical cardioversion)

Fast Pulse Tachycardia appropriate for the clinical condition

• Consider the cause….

• Treat the cause !

Slow PulseStable Patient

Sinus Bradycardia Heart Blocks

• Consider the cause– Prolonged hypoxemia– Drugs

Slow Pulse

• Consider the cause:

• 6 H’s and 5 T’s Hypovolemia Hypoxemia“Hydrogen Ion” Hypothermia Hypoglycemia Hyper /Hypokalemia

Slow Pulse

• Consider the cause:

• more H’s:Head Injury Heart Block

Heart TransplantHeart Disease

Slow Pulse

• Consider the cause:

• 5 T’sTamponade Tension

PneumothoraxToxins Thrombosis

Trauma

Slow Pulse Unstable Patient, Poor Perfusion

• Oxygenation and Ventilation• Chest Compressions (if heart rate still <60 despite O2 & vents)

• Epinephrine• ? Atropine• Pace Maker

Slow Pulse

• Epinephrine vs Atropine

NO Pulse

• Asystole• Ventricular Fibrillation (VF)• Pulseless Ventricular Tachycardia (VT)• Pulseless Electrical Activity (PEA)

No Pulse

• CPR ? Defibrillate• Ventilate with 100% oxygen• IV or IO access• Epinephrine q 3-5 minutes

No PulseAsystole or PEA

• CPR• Ventilate with 100% oxygen• IV or IO access• Epinephrine q 3-5 minutes• Treat Cause!• Perform flat line protocol

No Pulse

• Flat Line Protocol–Check Leads–Check in a different lead–Increase gain or size

No Pulse

•Consider cause:

6 H’s and 5 T’s

No PulsePulseless Ventricular Tachycardia or Fibrillation

• CPR• Defibrillate (as soon as available)• Resume CPR• Rhythm Check (Q2mins), if VF/VT

• Defibrillate• Give Meds• Resume CPR

• Alternate Epi with Amiodarone

Summary of Therapy by Pulse Rate

Fast(adequate perfusion) Vagal Maneuvers, Adenosine or

Amiodarone/Procainamide(poor perfusion) Cardioversion

Slow Ventilation / Oxygenation CompressionsEpi.

Absent CPRVF / VT: DefibrillationPEA/EMD: Identify & treat the cause

Epinephrine

Warning:

Treat the Patient Not the Rhythm

Drugs & Drips

Fluids “Drips” are use for:Volume Replacement & Delivery of Medications

Drips: Fluids of Choice

• Isotonic Crystalloids–Normal Saline–Lactated Ringer’s

• What if your patient is hypoglycemic?

Drugs: Sites for Administration

Peripheral veinsIntraosseousCentral veinsEndotracheal

When would you use an IO ?

When would you use an IO ?

Cardiopulmonary ArrestShock

Intractable seizures

When would you use ET ?

• What drugs can you give down the ET tube?

• L or L• E A• A N• N E

How do I do that? • Dilute the drug with 3-5 ml of NS• Instill directly into tube • Deliver positive pressure breaths

• Or Insert a catheter into ET tube • Instill drug via catheter• Flush with 3-5 ml of normal saline• Deliver positive pressure breaths

1

2

Drugs Dosages: ET / IO

• IO: same dose as IV

• ET:– Epinephrine dose is 10 times greater

0.1 mg/kg (use 1:1,000 strength)– Other drug are increased 2-3 times IV dose

“ Defib.”

Joules per kilogram

Post Arrest Shock

Optimize Ventilation and Oxygenation

Titrate O2 saturation to 94% - 99%

Advanced Airway

Waveform Capnography

Treat shock&

Contributing Factors

Review

• Dysrhythmias - fast, slow, none

• Drugs - Oxygen, Epinephrine

• Drips - Normal Saline

• Defibrillation - rare but know how !

• Questions ????