PEDIATRIC ARRHYTHMIAS TORY WEATHERFORD, PGY - 3

NO DISCLOSURES

NORMAL HEART RATE RANGES

PR INTERVAL LENGTHENS FROM INFANTS TO CHILDREN

QRS INTERVAL LENGTHENS

INTERVALS

REMINDER: T WAVES FLAT OR INVERTED IN NEWBORNS

T WAVE INVERSION IN RIGHT PRECORDIAL LEADS INTO CHILDHOOD/EARLY ADOLESCENTS

T-WAVES

Sinus arrhythmia P-P interval variation Exaggerated with respirations Maybe more pronounced in infants

Non – Pathologic Arrhythmia

Isolated premature ventricular beats (upto 40%)

Isolated supraventricular beats First degree A-V block Mobitz I sedond degree block Junctional arrhythmias

Other benign arrhythmias

Arrhythmias tend to be well tolerated Signs and symptoms – palpitations, fatigue,

syncope Neonates – poor feeding, irritablity

IN KIDS WITH STRUCTURALLY NORMAL HEARTS – MECHANISMS OF ARRYTHMIAS TEND TO BE SIMILAR TO ADULTS

MORE COMMON TO SEE – ACCESSROY PATHWAYS, ATRIAL FOCI, DUAL AV NODAL PHYSIOLOGY

IN STRUCTURAL ABNORMAL HEARTS – ARRTHYMIA 2/2 UNDERLYING ABNORMALITY, SURGICAL INTERVENTION, HEMODYNAMIC STRESS

Tachycardias

Upto 13% of pediatric arrhythmias Incidence of 0.1 – 0.4% 2 types – AV node re-entrant Tachycardia,

accessory pathway – AV reentry tachycardia

Supraventricular Tachycardia

ATRIOVENTRICULAR REENTRY TACHYCARDIA MUSCULAR PATHWAY ACCESSORY PATHWAY/ORTHODROMIC

TACHYCARDIA MOST COMMON TYPE OF SVT IN KIDS – 82%

ARRHYTHMIAS IN INFANCY

AVRT

RE-ENTRANT CIRCUIT THAT INVOLVES AV NODE

2 CONDUCTION LIMBS – FAST AND SLOW ~15% OF SVT IN PEDIATRICS

AVNRT

BOTH WELL TOLERATED OFTEN INDISTIGUISHABLE

SVT

ASYMPTOMATIC INFANTS – POOR FEEDING, IRRITABLITY,

PALLOR KIDS/TEENS – CHEST PAIN, DIZZINESS,

SYNCOPE, PALPITATIONS, SOB S/SX OF HEART FAILURE IN INFANTS IF

UNRECOGNIZED

CLINICAL FEATURES

HR >220 IN INFANTS, >180 KIDS NARROW QRS AV RATIO 1:1 AVRNT – ? TERMINAL QRS NOTCHING AVRT - ? INVERTED P WAVES

EKG FINDINGS

Short P-R interval Widened QRS Delta Wave

WPW

VAGAL MANUEVERS ADENOSINE CARDIOVERSION ABLATION

ACUTE MANAGEMENT

REPEAT EKG ONCE IN NSR LABWORK – ELECTROLYTES, TSH, CBC ADMISSION IF LESS THAN ONE, AND

HEMODYNAMICALLY UNSTABLE FIRST TIME EPISODE – OBSERVATION

OVERNIGHT CARDIOLOGY CONSULT – MANAGEMENT OF

MEDS CARDIOLOGY FOLLOW UP IF PRE-EXCITATION

ON EKG AND ASYPTOMATIC

FURTHER WORKUP

USUALLY IN NEWBORN PERIOD, UNLESS S/P CARDIAC SURGERY

COMMON S/P FONTAN, ASD REPAIR, AND TETRALOGY REPAIR

SINGLE REENTRY CIRCUIT HD INSTABILITY CORRELATES WITH DEGREE

OF BLOCK – 1:1 WORST

ATRIAL TACHYCARDIAS

OFTEN DIAGNOSED IN-UTERO FETAL HYDROPS IF PROLONGED MOST NEWBORNS ASYMPTOMATIC IF

TACHY< 48 HOURS INFANTS – POOR FEEDING, LETHARGY,

PALLOR, DIAPHORESIS OLDER KIDS – CHEST PAIN, PALPITATIONS,

DIZZINESS

CLINICAL FEATURES

Vagal maneuvers and adenosine may slow conduction revealing p-waves w/o termination

If Unstable – Cardioversion 0.5j/kg upto 1-2J/kg

If stable – Rate control with Bblockers, CCBs, rhythm control with amiodarone or ibutilide

Acute Management

Labs – CBC, lytes, thyroid function Cardiology consult & Echo to rule out

structural disease, thrombus formation Admit for obs Anticoagulation if >48 hour or s/p Fontan

Further workup

~10% SVT IN CHILDREN MCC OF TACHYCARDIA INDUCED

CARDIOMYOPATHY ETIOLOGY – VIRAL VS. TUMOR VS. GENETICS VARIABLE PRESENTATION – FAIRLY BENIGN

TO HEART FAILURE

ECTOPIC ATRIAL TACHYCARDIA

Responds poorly to adenosine and cardioversion

1st line – Amiodarone bolus 5mg/kg over 20-60 minutes

Maintenance drip 10-15 mg/kg/day If asymptomatic – no treatment

ACUTE MANAGEMENT

Labs – cbc, lytes, tsh Cardiology consult – echo, 24 hour monitor Treatment depends on age, cause,

symptomatology, clinical status If less than 1 year or symptomatic –

admission for arrhythmia management and cardiac failure

FURTHER WORKUP

MOST COMMON IN STRUCTURALLY ABNORMAL HEARTS, PRIOR CARDIAC SURGERY

STRUCTURALLY NORMAL HEARTS - ASSOCIATION WITH ACCESSORY PATHWAY CONDUCTION AND SUDDEN DEATH

SEEN IN MYOCARDITIS, PERICARDITIS, HYPERTHYROID, GENETIC CAUSES

ATRIAL FIBRILLATION

UNSTABLE – CARDIOVERSION 2J/KG STABLE – RATE VS RHYTHM CONTROL –

AMIODARONE/IBUTILIDE.

ACUTE MANAGEMENT

LABS – CBC, CHEMISTRY, THYROID, TOX FURTHER TESTING IF CARDIOMYOPATHY IS

CONSIDERED – BCS, VIRAL PANEL, ENZYMES ECHOCARDIOGRAM ADMISSION FOR OBS/TREATMENT ANTICOAGULATION IN MOST CASES

FURTHER MANAGEMENT

DDX: V-TACH SVT WITH BUNDLE BRANCH BLOCK SVT WITH PRE-EXCITATION IN WPW

TREATMENT – ALL AS VTACH, PRIOR EKGS CAN BE HELPFUL

WIDE COMPLEX TACHYCARDIAS

RARE - ~6% OF TACHYCARDIAS SUSTAINED VS NON-SUSTAINED MONOMORPHIC, REGULAR RATE, SINGLE

QRS MORPHOLOGY ETIOLOGIES: Idiopathic, drug toxicity,

cardiomyopathy, myocarditis, cardiac tumors and metabolic abnormalities

V-TACH

IF UNSTABLE – CARDIOVERSION AT 2J/kg then increasing

IF STABLE - Amiodarone at 5mg/kg IV over 30–60 minutes or procainimide at 15mg/kg IV over 30–60 minutes

ACUTE MANAGEMENT

Very thorough history – cardiomyopathy, toxins, family hx of sudden cardiac death

Ekg to r/o – Brugada syndrome, long Q-T, arrhythmogenic right ventricular cardiomyopathy, electrolyte abnormalities, structural heart disease, ischemia

Cardiology consult Echo Admission for observation ?Amiodarone gtt

FURTHER WORKUP

MAY CAUSE SUDDEN CARDIAC DEATH ABNORMALITIES IN ION CHANNELS ---

TORSADES, OFTEN PRECIPITATED BY ADRENERGIC STIMULI

ACQUIRED LONG QT 2/2 – DRUGS, ELECTROLYTE ABNORMALITIES, UNDERLYING MEDICAL CONDITION

CONGENITAL LONG Q-T

PRE-SYNCOPE, SYNCOPE, SEIZURES, OR CARDIAC ARREST

RARELY – INFANTS – POOR FEEDING, LETHARGY, CYANOSIS, POOR PERFURSION

PRECIPATING FACTORS – EXERCISE, SWIMMING, EMOTIONAL STRESS, LOUD NOISES

PRESENTATION

EKG FINDINGS: Sinus rhythm ECG, QTc of >460 in post-pubertal females and 450 in others, best obtained from lead II (Bazett Formula QTc= QT Interval/√-RR).

IF >440 AND correct clinical symptoms – further investigation

FOR TORSADES – DEFIBRILLATION, MAGNESIUM

CORRECT UNDERLYING PROBLEM IF ACQUIRED

IV BETA BLOCKERS MAY CALM ADRENERGIC STORM

ACUTE MANAGEMENT

THOROUGH HISTORY AND FAMILY HX, ESP HISTORY OF INCITING EVENT

MEDICATION REVIEW LABS – LOOKING FOR ELECTROLYTE ABNORMALITY IF IN VTACH – ADMIT FOR OBS, ECHO, CARDIOLOGY

CONSULT INCIDENTAL FINDING – OUTPATIENT CARDIOLOGY

FOLLOW UP SCREEN FAMILY MEMBERS WITH EKG

FURTHER MANAGEMENT

SHORT Q-T SYNDROME – SYNCOPE, HIGH RISK OF SUDDEN CARDIA DEATH

BRUGADA SYNDROME IDIOPATHIC V FIB SICK SINUS SYNDROME LEV-LENEGRE SYNDOME – PROGRESSIVE

CARDIAC CONDUTION DISEASE

OTHER CHANNELOPATHIES

DESPITE REPAIR – LIFETIME INCREASE IN ARRYTHMIAS

CONGENITAL HEART DISEASE

CHD & ASSOCIATED ARRHYTHMIA

TETRALOGY OF FALLOT ATRIAL TACHYCARDIADOUBLE OUTLET RV V TACH

SINUS NODE DYSFUNCTION

TRANSPOSITION OF VESSELS VENTRICULAR ARRHYTHMIAAV BLOCK

EBSTEINS ANOMALY SVT

VSD HEART BLOCKVENTRICULAR ARRHYTHMIA

ATRIAL SEPTAL DEFECT ATRIAL TACHYCARDIA

ASD REPAIR SINUS NODE DYSFUNCTION

HYPERTROPHIC CARDIOMYOPATHY DILATED CARDIOMYOPATHY ARRYTHMOGENIC RIGHT VENTRICULAR

DYSPLASIA VTACH AND SUDDEN DEATH EKG – RIGHT VENTRICULAR CONDUCTION

DELAY, INVERTED T WAVES, AND PVCS PRESENTS WITH SYNCOPE DURING EXERCISE

CARDIOMYOPATHIES

CLASS I – SECONDARY PROPHYLAXIS AFTER CARDIAC

ARREST WHERE NO REVERSIBLE CAUSE WAS FOUND IN A NORMAL HEART, CHD, CARDIOMYOPATHIES OR CHANNELOPATHIES

SYMPTOMATIC SUSTAINED VT IN PATIENTS WITH CHD

SYMPTOMATIC SUSTAINED VT IN PATIENTS WITH CARDIOMYOPATHIES AND SIGNIFICANT LV DYSFUNCTION

INDICATIONS FOR ICD

CLASS II INDICATIONS: CHD WITH RECURRENT SYNCOPE AND

VENTRICULAR DYSFUNCTION OR INDUCIBLE VENTRICULAR ARRHYTHMIAS

LONG QT SYNDROME AND MEDICATION NON COMPLIANCE, OR FAMILY HX OF SUDDEN DEATH

HCM WITH 1 OR MORE RISK FX – HX OF SUDDEN DEATH, NON RESPONSIVE TO MEDS

ICDS

TINTINALLI’S EMERGENCY MEDICINE CROSSON, HENASH “EMERGENCY

DIAGNOSIS AND MANAGEMENT OF PEDIATRIC ARRHYTHMIAS” JOURNAL EMERGENCY TRAUMA AND SHOCK 2010 SEPTEMBER 251-260.

Uptodate “Irregular Heart Beats in Children” http://lifeinthefastlane.com/ecg-library/paedi

atric-ecg-interpretation/

REFERENCES

EHRA/AEPC CONSENSUS STATEMENT “Pharmacological and non-pharmacological therapy for arrhythmias in the pediatric population: EHRA and AEPC-Arrhythmia Working Group joint consensus statement” JULY 12, 2013

http://www.pedicardiology.net/search/label/EKG

REFERENCES