Evaluation & Management of Pediatric Arrhythmias

2. Evaluation & Management of a Child with Arrhythmias By Dr.SaimaBashir Post Graduate Trainee Pediatric medicine unit-I Mayo Hospital Lahore

3. Definition Cardiac arrhythmia (also dysrhythmia) is a term for any of a large and heterogeneous group of conditions in which there is abnormal electrical activity in the heart. The heart beat may be too fast or too slow, and may be regular or irregular.

4. Classification Of Arrhythmias Tachycardia Bradycardia Sinus tachycardia SVT Vent. Fib Vent. Tachy Atril fib. Atrial flutter Sinus bradycardia Heart block Irregular Sinus arrhythmia PAC PVC

5. Causes Of Arrhythmias Congenital Acquired In structurally normal/ abnormal heart Congenital metabolic disorders of mitochondria SLE Rheumatic fever Myocarditis Toxin (diphtheria) Pro-arrhythmic or anti-arrhythmic drugs Surgical correction of CHD

6. Why Basic Understandning Of Arrhytmias Is Important??? Major risk of an arrhythmia is either severe bradycardia or tachycadiadec. cardiac output degeneration into more severe arrhythmias (vent. fib.) To be aware of arrhythmias that occur in otherwise healthy children

7. Symptoms Range from Completely asymptomatic Loss of consciousness Sudden cardiac death In infants Lethargy Poor feeding Irritability Cardiac failure Underlying congenital heart disease In children Palpitation Syncope Dizziness Chronic fatigue Shortness of breath Chest discomfort

8. Examination GPE Pulse__ irregular, feeble, inc./dec. rate, absent Tachypnea B.P __ Normal, hypotension JVP __ raised in CCF Cyanosis Pallor CVS Precordial bulge Right ventricular heave Gallop Murmur

9. Respiratory system Bil. Crepts (pulm. edema) GIT Hepatomegaly CNS Normal Hpotonia

10. Evaluation Of The Child With An Arrhythmia History Symptoms Frequency and length of episode Onset and triggers Any underlying disease Medications Triggering factor Used for underlying cardiac disease

11. Evaluation Of The Child With An Arrhythmia Physical examination ABC’s Hemodynamic stability Adjunctive testing 12-Lead ECG Holter External event recorders Exercise testing

12. Evaluation Of The Child With An Arrhythmia Patient with arrhythmia Ensure ABCs Absent Asystole Assess rhythm V FIB Pulseless V Tach PEA Absent Assess pulse Present Irregular Fast Slow Narrow QRS Wide QRS Sinus Bradycardia AVN Block Sick Sinus Sinus arrhythmia Atrial FIB PAC +/- Block PVC Sinus Tachycardia SVT (PAT) Atrial flutter V TACH V FIB

13. Evaluation Of The Child With An Arrhythmia Assess Pulse Irregular Fast Slow P- Wave PR-Interval Prolonged PR-Interval Normal Heart- block Sinus Bradycardia

16. P- Wave PresentWide QRS- complex Sinus Arrythmia PVC PAC Atrial Fib.

18. low amplitude QRS- ComplexSinus trachycardia SVT Atrial flutter V- Tech V- Fib.

19. Pediatric Dysrhythmias Reproduced from Zitelli’s Atlas of Pediatric physical diagnosis, 2007, pg 140.

20. Sinus Rhythm Every QRS complex is preceded by a P wave and every P wave must be followed by a QRS (the opposite occurs if there is second or third degree AV block). The P wave morphology and axis must be normal and PR interval will usually be normal for that age

21. Sinus Arrhythmia Most common irregularity of heart rhythm seen in children Normal variant Reflects healthy interaction between autonomic respiratory and cardiac control activity in CNS Heart rate increases during inspiration and decreases during expiration

22. Sinus Arrhythmia Normal phasic variation of heart rate with respiration Variable P-P intervals No treatment needed

23. Wandering Atrial Pacemaker normal QRS complex Change in P-wave configuration

24. Atrial pacemaker shifts intermittently from sinus node to another atrial site Normal variant May also be seen in CNS disturbances like subarachnoid hemorrhage Wandering Atrial Pacemaker

25. Premature Atrial Contraction Ectopic focus in atria or AV node Narrow but normal QRS Normal P wave

26. Isolated PAC’s Premature atrial contractions Benign in absence of underlying heart disease Common in newborn period Early p wave, sometimes with different morphology than a sinus p wave Can be either: Not conducted to ventricle, apparent pause Conducted to ventricle with aberrant or widened QRS complex ( careful not to mix up with PVC’s)

27. Premature Ventricular Contraction Ectopic beat activates ventricle before the wave of depolarization from normal sinus node Abnormally wide QRS complex appears early which are not preceded by P-wave T-wave points in the direction opposite to QRS complex Bigeminy, trigeminy, couplet Unifocal, multifocal Three or more successive PVCs are termed as ventricular tachycardia

28. Premature Ventricular Contraction Not very commonly seen in children Incidence of 0.3 to 2.2 % Myocarditis cardiomyopathy CHD hypokalemia Hypoxia Drugs:Digitalis toxicity, catecholamines, theophylline, caffeine, anesthetics, Class I and III anti-arrhythmics myocardial injury long QT syndrome hypomagnesemia

29. unifocal, disappear with exercise, and associated with structurally and functionally normal heart, then considered benign, no therapy needed PVC’s

30. PVC’s Evaluation Indicated if Two or more PVCs in a row Multifocal origin Increased vent. Ectopic activity with exercise R on T phenomenon (PVC occurs on preceding beat) Presence of underlying heart disease

32. IV lignocaine – 1st line drug

34. Sinus Bradycardia Normal P wave axis and P-R interval HR < 5th percentile for age

35. Sinus Bradycardia Athletic individuals (normal) Increased ICP hyperkalemia vagal stimulation hypothermia Drugs: digoxin, beta-blockers, clonidine, opiods, sedative-hypnotics, amiodarone Treatment: address underlying cause hypoxia hypercalcemia hypothyroidism long QT syndrome

36. Long Q-T Syndrome Bradycardia Prolonged QT interva Notched T- wave

37. Long Q-T Syndrome Genetic abnormality of vent. Repolarization 50% cases familial Romano Ward syndrome – common form of LQTS Drugs causing LQTS: terfenadine, cisapride, droperidol Clinical manifestation: Syncope induced by exercise, fright, startle Some events occur during sleep Seizures Palpitation Cardiac arrest (10%)

38. Long Q-T Syndrome Diagnostic criteria: QTc >0.47 __ indicative QTc >0.44 __ suggestive Notched T- wave Low heart rate for age Syncope Family H/O LQTS or unexplained sudden death Investigation 12 lead ECG Holter Monitoring Exercise testing

39. Long Q-T Syndrome Treatment: Beta blockers __ to blunt heart response to exercise Pacemaker if drug induces profound bradycardia Implanted cardiac defibrillators Continuous syncope No response to drug treatment Experienced cardiac arrest

40. Sick Sinus Syndrome Result of abnormality in sinus node or atrial conduction pathway or both Arrhythmias include sinus bradycardia, blocks, sinus arrest with junctional escape, paroxysmal atrialtachycadia. Most common after surgical correction of CHD Clinical manifestations depend on heart rate Asymptomatic Dizziness Syncope Treatment: pacemaker therapy in symptomatic patient

42. Provide 100% oxygen

43. Attach monitor

45. Support ABCs

48. Hypothermia

49. Heart block

50. Heart transplant

52. Endotracheal tube: 0.1mg/kg (1:10,000; 0.1 ml/kg)

56. Attach monitor

57. Vascular Access

58. Assess and supports ABC’s

60. Attach monitor

62. Support ABCs

63. Consider tranfer or transport to ALS facility

64. Observe

65. Support ABCs

68. Hypothermia

69. Heart block

73. Hypothermia

74. Heart block

81. AV Nodal Block First- Degree Heart Block Delayed conduction through AV node Prolongation of PR interval

83. 80-220 msec in young children and adultsGenerally does not cause bradycardia since AV conduction remains intact

85. Lyme disease,

86. CHD (ASD, Ebstein’s anomaly),

87. cardiomyopathy,

88. post-cardiac surgery,

89. normal children

90. Hypothermia

92. Second-Degree Heart Block:Mobitz Type I - Wenckebach P Progressive lengthening of PR interval until a QRS is not conducted (ventricular contraction does not occur)

94. cardiomyopathy,

95. CHD,

96. cardiac surgery,

97. MI,

98. normal children at times of increased parasympathetic activityDrugs: digitalis toxicity, beta-blocker toxicity Treatment: address underlying cause

99. Second-Degree Heart Block:Mobitz Type Il Constant PR interval before a skipped ventricular conduction

100. Block below the AV node in the bundle of His Not found in normal children, usually those with structural disease or post-op May progress to complete heart block May require pacemaker Second-Degree Heart Block:Mobitz Type Il

101. Third-Degree Heart Block: Complete Complete dissociation of atrial and ventricular conduction P wave and PR interval normal Junctional pacemaker – narrow QRS Ventricular pacemaker – wide QRS Rate 30 – 50 beats/min

102. Third-Degree Heart Block: Complete Congenital: maternal lupus or CT disease, CHD (L-TGA or abnormal AV septum) Acquired: post-op, acute rheumatic fever, Lyme carditis, myocarditis, cardiomyopathy, MI Slower the heart rate, and wide QRS escape rhythms place into high risk group May need implantable pacemaker: significant bradycardias, syncope, exercise intolerance, ventricular dysrhythmias, or ventricular arrhythmias, structural disease Possible acute treatment: isoproterenol

103. Sinus Tachycardia Normal sinus rhythm HR >95th percentile for age Usually < 230 beats/min

104. Sinus Tachycardia Hypovolemia Anemia fever CHF Drugs: Beta-agonists, aminophylline, atropine Treatment: address underlying cause. shock Sepsis anxiety

105. Supraventricular Tachycardia > 230 beats/min Narrow QRS P waves not visible

110. SVT - Presentation Older kids can describe a sensation of a fast heart rate, palpitations, or chest tightness Hemodynamic compromise (CCF) in newborns and those with structural heart disease

112. differentiate from sinus tachycardia, and

115. Provide oxygen and ventilation as needed

116. Attach monitor

118. P-wave absent/ abnormal

119. HR not variable with activity

120. Abrupt rate changes

121. Infant : rate usually >220 bpm

123. P-wave present/Normal

124. HR often varies with activity

125. Variable RR with constant PR

126. Infant : rate usually <220 bpm

128. Conform continuous monitor

129. Medical control consultation

131. May double and repeat dose once (maximum 2nd dose of 12 mg)

132. Techniques: use rapid bolus techniqueIdentify and treat possible causes Hypoxemia tamponade Hypovolemia tension pneumothorax Hyperthemiaposion/ toxin / drugs Hyper-/ hypokalemiathromoembolism Any further out of hospital interventions require medical control Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg

135. Attach monitor

156. Techniques: use rapid bolus techniqueIdentify and treat possible causes Hypoxemia Tamponade Hypovolemia Tension pneumothorax HyperthemiaPosion/ toxin / drugs Hyper-/ hypokalemiaThromoembolism Any further out of hospital interventions require medical control Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg Any further out of hospital interventions require medical control Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg

173. Use sedation if possible

175. Dose: Adenosine 0.1mg/kg lV/lO (max 1st dose of 6 mg)

176. May double and repeat dose once (max 2nd dose of 12 mg)

180. Prepare for cardio version (consider sedation) 0.5 to 1.0 j/kgIdentify and treat possible causes Hypoxemia tamponade Hypovolemia tension pneumothorax Hyperthemiaposion/ toxin / drugs Hyper-/ hypokalemiathromoembolism

183. Attach monitor

184. Provide oxygen or ventilation as needed

186. Evaluate QRS duration

187. 12 lead ECG if practical

223. Very effective

225. Impulse arrives at ventricle rapidly without delay at the AV node

226. Independent of AV node

228. slurred upstroke of QRS

229. Reflects pre-excitation

230. Short PR- interval

232. Atrial Flutter Chronic atrial flutter: Inc. risk of thromboembolism and stroke Anticoagulation Radiofrequency ablation in CHD in older child Management Emergency: Vagal maneuver adenosine Synchronized cardioversion0.5-2 J/kg Overdrive pacing Long term: Digoxin+/- B- Blockers Ablation

233. Atrial Fibrillation Atrial rate 350-600 beats/min Atrial waves are totally irregular P wave vary in size and shape from beat to beat vent. response is irregularly irregular QRS complexes are usually normal

234. Atrial Fibrillation Much less common Chronically stretched atria Intra atrial surgery Left atrial enlargement due to mitral valve insufficiency WPW syndrome Thyrotoxicosis Pulm. Embolism Pericarditis familial

235. Atrial Fibrillation Treatment: Restore normal heart rate by digitalization (avoided in WPW syndrome) Restore normal rhythm by adding quinidine/procainamide/DC cardioversion Prevention of thromboembolic phenomenon and stoke by warfarin

236. Ventricular Tachycardia 120-150 beats/min Wide QRS 3 or more consecutive beats from the ventricle (PVCs) 85% have abnormal cardiac anatomy Metabolic abnormalities Drugs/toxins: tricyclic antidepressants

237. V-Tach Associated with Myocarditis Anomalous origin of coron. A. Rt. Vent. Dysplasia Mitral valve prolapse CMP LQTS WPW synd. Drugs(cocaine, amphetamine)

238. V-Tach Treatment: IV lidocaine, procainamide, amiodarone If critically ill: synchronized cardioversion Long term: meds, ablation, or defibrillator

242. Attach monitor

258. Techniques: use rapid bolus techniqueIdentify and treat possible causes Hypoxemia tamponade Hypovolemia tension pneumothorax Hyperthemiaposion/ toxin / drugs Hyper-/ hypokalemiathromoembolism Any further out of hospital interventions require medical control Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg

261. Attach monitor

280. Techniques: use rapid bolus techniqueIdentify and treat possible causes Hypoxemia Tamponade Hypovolemia Tension pneumothorax HyperthemiaPosion/ toxin / drugs Hyper-/ hypokalemiaThromoembolism Identify and treat possible causes Hypoxemia tamponade Hypovolemia tension pneumothorax Hyperthemiaposion/ toxin / drugs Hyper-/ hypokalemiathromoembolism Any further out of hospital interventions require medical control Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg Any further out of hospital interventions require medical control Consult for possible sedation & cardio version orders 0.5 to 1.0 j/kg

307. Attach monitor

308. Provide oxygen or ventilation as needed

310. Evaluate QRS duration

311. 12 lead ECG if practical

336. Ventricular Fibrillation Rapid and irregular ventricular arrhythmia Low amplitude QRS primary form or from degeneration of unstable SVT Rare in children MI, post-op, myocarditis, severe hypoxia, long QT syndrome Digitalis and quinidine toxicity, catecholamines

337. V-fib Presents with pulse less cardiac arrest Fatal dysrhythmia. Death if untreated/uncorrected Thump on chest may occasionally restore sinus rhythm Treatment: immediate defibrillation, CPR

345. Antiarrhythics

347. Hypovalemia

348. Hypothermia

349. Hyperkalemia/ hypokalemia and metabolic disorders

350. Tamponade

351. Tension pneumothorax

352. Toxins/poisons/drugs

356. Attach monitor

357. Assess and supports ABC’s

362. Antiarrhythics

364. Hypovalemia

365. Hypothermia

367. Tamponade

375. Antiarrhythics

377. Hypovalemia

378. Hypothermia

380. Tamponade

386. Q Q ? ? ? Q Q ? Q Q ? ? ? ? ? ? ? Q Q ? ? ? ? Q

387. Curious Minds = Successful Minds

388. qUiZ

389. 3

390. 2

391. 1

392. What is sinus rhythm? When each P-wave is followed by QRS- complex When each QRS-complex is preceded by P-wave Normal P-wave and PR interval All of above Q

393. Q: This is the ECG of a 2yr old girl presented with history of vomiting and fast heart rate What two abnormalities are shown up on ECG? What is most likely diagnosis? Three possible therapeutic procedure?

394. A Tachycardia(Heart rate 214/min) No P-wave Supraventricular Tachycardia Carotid sinus message Submerge face in cold water or put an ice bag on face lV Adenosine

395. This is the ECG of six year old boy referred to the output patient clinic with a heart murmur What three abnormalities are shown in ECG What is diagnosis? Name two complications which may arise? Q:

396. A Short PR interval Wide QRS Delta Waves Wolf parkinson-White-Syndrome Supraventricular tachycardia Heart block

397. Q: What is diagnosis? What treatment is required in a asymptomatic patient without underlying heart disease if these disappear with exercise?

398. A PVC No Treatment

399. Q: What is diagnosis? What is immediate treatment?

400. A Venticular fib. Defibrillation

401. Comments & Suggestions

Evaluation & Management of Pediatric Arrhythmias

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