PALS 3 (before EPC)

Management of Arrhythmia in Pediatric Patients

Introduction to Arrhythmias

  • Focus on management of arrhythmia (abnormal heart rhythm) in emergency pediatric patients.

  • Recognition and treatment algorithms can be found in the provider manual.

Factors to Consider in Evaluation

  • Consider the child's typical heart rate, baseline rhythm, level of activity, age, and clinical condition when evaluating.

Signs of Instability in Patients with Arrhythmia

  • Respiratory distress or failure

  • Shock with poor end organ perfusion: May occur with or without hypotension.

  • Irritability or decreased level of consciousness

  • Chest pain or vague discomfort in older children.

  • Sudden collapse

Common Pediatric Arrhythmias

  1. Sinus bradycardia

  2. Atrioventricular (AV) Block

  3. Sinus tachycardia

  4. Supraventricular tachycardia (SVT)

Bradycardia Management

  • Definition: Bradycardia is characterized by a heart rate lower than normal.

  • Most serious cause of bradycardia in children: Severe hypoxia

  • Initial Treatment:

    • Administer bad mass ventilation with 100% oxygen.

Bradycardia Algorithm

  • Initial Treatment: Ventilations

  • If heart rate is below 60 bpm, continue ventilations.

  • Heart rate of 20 bpm does not necessarily indicate immediate CPR. Focus on ventilations first.

    • Reasoning: Similar to neonates, emphasis on ventilations before compressions.

  • If bradycardia persists and heart rate is < 60 bpm with poor perfusion: Start CPR and consider administering epinephrine or atropine.

Signs and Symptoms to Monitor

  • Monitor mental status, signs of shock, and additional indicators of potential cardiopulmonary compromise.

  • Determine whether airway is open and if child is breathing adequately.

  • If ventilation is unresponsive, start CPR if heart rate remains below 60 despite oxygenation.

Evaluating Effectiveness of Ventilations

  • Effective ventilations are indicated by chest rise.

  • Increase in heart rate during ventilation is expected (e.g., from 20 to 32 bpm). Continue intervention if heart rate progresses.

  • If no improvement, initiate CPR.

Patient Considerations

  • Not every child with a heart rate below 60 requires CPR; consider presentation and instability of the patient.

  • Symptomatic patients showing signs of shock need immediate treatment, including potential for medications like atropine and epinephrine.

  • For AV block or vagal stimulation, atropine may be considered earlier depending on situation.

Administration of Epinephrine and Atropine

  • Epinephrine is often used for bradycardic children, administered differently than for adults (e.g., Epidose instead of Epidrip).

  • Note: Giving medications via ET tube is less effective and not recommended due to the necessity of a higher dose (triple the normal).

Pacing in Bradycardia

  • Use anterior-posterior positioning for pacing.

  • Initial pacing settings: Start at 70 milliamps, may reduce to 30-40 milliamps for children.

Transitioning Treatments

  1. If still bradycardic while doing CPR, consider pacing as an alternative.

  2. Pacing doesn't mean you stop compressions; it's a trial and may require reassessment of interventions.

  3. Post-cardiac arrest: Continue compressions until other interventions like pacing show improvement.

Tachycardia Management

  • Key in differentiating between sinus tachycardia and other forms leading to interventions like adenosine.

  • Importance of understanding the patient's history/stories contributing to tachycardia.

  • Administer fluid bolus to children in sinus tachycardia to maximize treatment effectiveness.

Considerations for Cardioversion and Adenosine

  • Know your synchronized cardioversion doses for SVT and other conditions.

  • Be aware of vagal maneuvers (e.g., cold packs to the face) that can assist in managing tachycardia.

  • For pediatric cardiac arrest algorithms, similarities to adult protocols exist, with dosage being the main difference.

Conclusion

  • Emphasis on practical application and recognizing the nuanced differences in pediatric treatment compared to adults.

  • Encourage practice and review of algorithms in upcoming sessions.