PALS 2020 ARRHYTHMIAS

Cardiopulmonary compromise

* Hypotension * Acutely altered mental status * Signs of shock

Cardioversion joules example w/ 6kg. Second dose?

1 j/kg x6kg= 6 joules 2 j/kg x6 kg= 12 jouls

How many joules should be used for the 1st shock? How many for the 2nd shock?

2 j/kg 4 j/kg

To optimize preload in a post cardiac arrest child, what fluid bolus amount should be administered?

5 to 10 mL/kg over 10 to 20 minutes

How much normal saline do you rapid flush after adenosine 0.1 mg/kg is given?

5-10 mL

Second degree AV block

A block of some but not all atrial impulses before they reach the ventricles. Block can be classified as Mobitz type 1 or Mobitz type 11

Bradycardia

A heart rate that is slow in comparison with a normal heart rate range for the childs age, level of activity and clinical condition

Sinus Tachycardia

A rapid heart rate that develops when high cardiac output is needed such as fever, excitement, and exercise. Normal response to stress or fever.

Primary bradycardia

A result of congenital or acquired heart conditions

If amiodarone or procainamide does not terminate the rapid rhythm, why should adenosine be considered?

A wide complex tachycardia could be SVT with aberrant ventricular conduction

For a stable pt with a regular wide complex and monomorphic tachycardia what should be considered?

Adenosine

if initial dose of adenosine 0.1 mg/kg does not work what is our next action? Max dose?

Administer a second dose of adenosine at 0.2 mg/kg (max second dose of 12 mg)

tachyarrhythmias

Are rapid abnormal rhythms originating either in the atria or the ventricles. They can be tolerated without symptoms for a variable period of time, especially if cardiac function is good.

When is atropine preferred over epi?

As the first choice treatment of symptomatic AV block due to primary bradycardia. Atropine not recommended for secondary brady

What rhythms is cardiac arrest associated with?

Asystole PEA V-Fib Pulseless v-tach

In hospital and out of hospital pediatric cardiac arrest whats the most common initial rhythms seen?

Asystole and pulseless electrical activity (PEA)

What is the initial treatment of pediatric bradycardia with cardiopulmonary compromise?

Bag mask ventilation with 100% O2

How are tachycardia and tachyarrhythmias classified?

Based of the width of the QRS complex. Narrow 0.09 seconds or less vs wide( greater than 0.09 seconds)

What electrocardiographic characteristics are consistent with sinus tachy?

Beat to beat variability with changes in activity

Sinus Bradycardia

Bradycardia associated with a disturbance called bradyarrhythmia. Sinus Bradycardia is not necessarily problematic. Present in children at rest when metabolic demands of the body are low (during sleep)

Sinus Tachycardia treatments

By treating underlying cause

Initial steps of VF/pVT pathway of pediatric cardiac arrest?

CPR Establish IV/IO access Deliver 1 shock

If rhythm of VF/pVT is terminated after 2 minutes of CPR and Epi what should be done?

Check for an organized rhythm ( check pulse) No organized rhythm (asystole/PEA) resume cpr

With VT rapid ventricular rate does what?

Compromises ventricular filing, stroke volume, and cardiac output and may deteriorate into pulseless VT or Vfib

Causes of primary bradycardia

Congenital abnormality of the heart pacemaker or conduction system Surgical injury to the pacemaker or conduction system Cardiomyopathy Myocarditis

What should be provided during 1st phase of post cardiac arrest management?

Continue to provide advanced life support for immediate life threatening conditions and focus on the ABCs

What precaution should be taken when performing ice on face vagal maneuver?

DO not cover the nose or mouth

Whenever a child has an abnormal heart rate or rhythm, you must quickly determine?

Determine if the arrhythmia is causing hemodynamic instability or other signs of deterioration.

Fine V- FIB

Electrical activity is reduced as compared with coarse VF

How should appropriate ET tube placement be confirmed?

End tidal CO2 or capnography

What is considered part of post cardiac care arrest?

Ensuring adequate analgesia and sedation Providing adequate oxygenation and ventilation Correcting acid base and electrolyte imbalances

What medication is indicated for symptomatic bradycardia that persists despite effective oxygenation and ventilation.

Epinephrine

If mycardial function remains poor in a post cardiac arrest child, what medications should be considered?

Epinephrine Milrinone

Repeat epi administration how often? For continuous bradycardia give how much epi?

Every 3 to 5 minutes as needed Give continuous infusion of epi (0.1 to 0.3 mcg/kg per minute)

Children with severe cardiovascular compromise from pulmonary embolism, what treatment should be considered?

Fibrinolytic agents

Arrest rhythm may be noted on the cardiac monitor but monitoring is not mandatory for?

For recognizing cardiac arrest

When should you give atropine before epinephrine?

Give atropine instead of epi for bradycardia caused by increased vagal tone, cholinergic drug toxicity or complete AV block

ECG characteristics of Bradycardia HR P wave QRS complex Pwave and QRS complex

HR Slow compared with normal heart rate for age P wave May or may not be visible QRS complex Narrow or wide Pwave and QRS complex: may be unrelated

Signs and symptoms of SVT?

HR does not vary with activity HR 220/min or greater in infants and 180/min or greater in child Absent or abnormal P waves

Signs and symptoms of sinus tachycardia

HR less than 220 in infants, less than 189 in a child Present and normal p waves HR vaires with activity or stimulation

Symptomatic Bradycardia

Heart rate below 60/min associated with cardiopulmonary compromise

Signs of hemodynamic instability associated with tachyarrhythmias?

Hypotension Altered mental status Signs of shock Additional sign can be sudden collapse with rapid, weak pulses Respiratory distress or failure

secondary bradycardia causes

Hypoxia Acidosis Hypotension Hypothermia Drug effects

Sinus bradycardia can develop in response to?

Hypoxia, hypotension, and acidosis. Its often the result of progressive respiratory failure or shock and indicates impending cardiac arrest

Two pathways to cardiac arrest are?

Hypoxic/asphxial Sudden cardiac arrest

Atropine dosing

IV/IO give 0.02mg/kg; 0/1 mg, max 0.5 mg. May repeat once in five minutes Larger doses are needed for organophosphate Endotracheal 0.04 to 0.06 mg/kg

Second degree Mobitz type 11

Identified by intermittently nonconducted p waves, with constant pr interval

For optimal post cardiac arrest care what should be done?

Identify and treat organ system dysfunction

What does optimal post cardiac care include?

Identifying and treating organ system dysfunction

Why would a shock not be delivered with synchronized cardioversion?

If R waves of tachycardia are undifferentiated or of low amplitude. The monitor sensors may be able to unable to identify them and wont deliver the shock

After resuscitation from cardiac arrest or shock, what can cause hemodynamic compromise

Increased systemic vascular resistance decreased cardiac contractility inadequate intravascular volume

Epinephrine Effects of epi may be reduced by?

Increases HR and cardiac contractility and causes vasoconstriction Reduced by Acidosis and hypoxia

Atrial flutter

Is a narrow complex tachyarrhythmia that can develop in newborn infants with normal hearts. It can develop in children with congenital heart disease, especially after cardiac surgery. Atrial rate can exceed 300/min, whereas the ventricular rate is slower and may be irregular

Why is sedation necessary with synchronized cardioversion? What should be done before cardioversion?

It is very painful. Whenever possible, establish vascular access and provide procedural sedation and analgesia before cardioversion, ESPECIALLY in a hemodynamically stable pt

Atropine

Its a parasympatolytic drug that accelerates the sinus or atrial pacemakers and enhances av conduction

Atrioventricular blocks (AV)

Its another type of bradycardia. AV block is a disturbance of electrical conduction through the AV node.

Epinephrine dosing

Iv/IO give 0.01 mg/kg (0.1mL/kg of 0.1mL concentrated Endotracheal 0.1 mg/kg(0.1mL/kg of 0.1mL concentrated)

sudden cardiac arrest

Less common in children, its most often caused by sudden development of ventricular fibrillation or pulseness v tach

What hr is consistent with sinus tachycardia?

Less than 220 in infants Less than 180 in children

signs and symptoms of Tachyarrhythmias? Clinical findings?

May cause nonspecific signs and symptoms that differ according to the childs age. Clinical findings may include palpitations, light headedness, and syncope

Supraventricular tachycardia

Most common arrhythmia in children SVT is generally characterized by an abrupt increase in HR that does not vary with activity This isnt a life threatening problem. Treatment is only necessary for prolonged episodes, or cause cardiorespiratory compromise

ventricular fibrillation

No organized rhythm and no coordinated contractions. Chaotic electrical activity with no identifiable P, QRS or T waves

Third degree av block

None of the atrial impulses conduct to heart ventricles. May be referred to as complete heart block or complete av block

What is considered an initial management priority in managing tachyarrhythmias?

Obtain 12 lead ecg is possible Assess and support airway, oxygenation and ventilation Attach electrocardiographic monitor/defibrillator and pulse ox

Cardiac arrest

Occurs when blood circulation ceases bc of absent or ineffective cardiac mechanical activity. Clinically the child is unresponsive and not breathing, and is pulseless

When is sinus bradycardia present?

Often present in healthy children at rest when metabolic demands of the body are relatively low (During sleep). because they have high stroke volume and vagal tone

Second degree mobitz type 1

Or Wenckebach type. Theres prolongation of the PR interval preceding nonconducted Pwaves

Unshockable rhythms

PEA and asystole

What pulse should you check if a child is unresponsive and does not have normal breathing?

Palpate a central pulse (brachial in an infant, carotid or femoral in a child)

What should be done for a stable pt in Supraventricular tachycardia?

Place bag with ice water over the upper half of the infants face Ask older child to blow through an obstructed straw

If in VF/pVT what should be done

Place defibrillator on pt and give 1 unsynchronized shock.

First degree AV block

Prolonged PR interval representing slowed conduction through AV node

What is chest compression fraction?

Proportion of the time that compressions are performed

2nd phase of post cardiac arrest management?

Provide broader multiorgan supportive care

How many joules is needed for synchronized cardioversion? If initial dose is ineffective?

Requires less energy than defibrillation. Energy dose of 0.5 to 1 j/kg for cardioversion of SVT or V tach with a pulse Increase the dose to 2 J/kg

What are the signs of instability in a patient with arrhythmias?

Respiratory distress or failure Shock with poor end-organ perfusion, may occur with or without hypotension Irritability or decreased level of consciousness Irritability or decreased level of consciousness chest pain or vague feeling of discomfort in older children sudden collapse

Secondary bradycardia

Result of noncardiac conditions that alter the normal function of the heart (Slow sinus node pacemaker or slow conduction)

While defibrillator is charging what can be done?

Resume chest compressions, if IV/IO access is established administer epi 0.01 mg/kg, and consider an advanced airway

rosc

Return of spontaneous circulation

Bradycardia is an ominous sign of?

Sign of impending cardiac arrest in infants and children. Especially if hypotension or poor tissue perfusion is present

Narrow complex tachycardia

Sinus tachycardia, supraventricular, and atrial flutter are classified as narrow complex.

What history is consistent with with SVT?

Symptoms of congenital heart disease

why does sinus tachycardia occur?

The body needs increased cardiac output

Priorities in initially managing arrhythmias are?

The same as they are for all critically ill children: Support ABC and treat underlying cause

What must be activated each time synchronized cardioversion is attempted?

The sync button must be activated. Because most devices will default to an unsynchronized shock right after delivery of synchronized shock

Well conditioned athletes often have Sinus bradycardia because

They have high stroke volume and increased vagal tone.

Hypoxic/asphyxial

This Arrest is the most common cause of cardiac arrest in infants, children and adolescents. End result of progressive hypoxia and acidosis

What is the leading cause of symptomatic bradycardia in children?

Tissue hypoxia

Cardiac arrest signs

Unresponsive Normal breathing or gasping (agonal gasps) No pulse (assess for 10 seconds)

Shockable rhythms are

Ventricular Fibrillation & Ventricular Tachycardia

Wide complex tachycardia

Ventricular tachycardia and supraventricular tachycardia with aberrant interventricular conditions

Characteristics of V tach

Wide QRS complex generated within the ventricles A rapid rate compromises ventricular filing Rapid rate may deteriorate into pulseless v tach or v fib

ventricular tachycardia

Wide QRS complex tachyarrhythmia generated within the ventricles. VT is uncommon in children. QRS complex greater than 0.09 seconds Ventricular rate is 200/min

Pulseless Electrical Activity

a condition in which the heart's electrical rhythm remains relatively normal, yet the mechanical pumping activity fails to follow the electrical activity, causing cardiac arrest

Asystole

absence of contractions of the heart

When treating persistent VF/pVT during cardiac arrest, administer epi

every 3 to 5 minutes

Synchronized Cardioversion is used for what arrhythmias?

is the electrical management of choice for atrial fibrillation, supra ventricular tachycardia (SVT) ventricular tachycardia with a pulse.

Fibrinolytic agents

tissue plasminogen activator, streptokinase, reteplase tenecteplase

vagal maneuvers

tx SVT, blowing on thumb (valsalva), ice to face, holding breath then bearing down, massaging carotid on one side of neck. if they do not work, give IV adenosine (antiarrythmic)