General Approach to All Pediatric Patients

Cardiac Arrhythmia - Pediatric

Bradycardia

Basic Life Support

  • Supplemental 100% oxygen
  • Open airway using head tilt-chin lift method
  • Assist ventilation as needed using Bag-Valve-Mask
  • Look for signs of airway obstruction
    • Absent breath sounds, intercostal retractions, stridor, choking, bradycardia or cyanosis

Advanced Life Support

  • Full Pediatric ALS Assessment and Treatment
  • Identify and treat possible causes of bradycardia:
    • If hypoxia open airway, assist breathing
    • If hypothermic, re-warm
    • If acutely deteriorating head injury, hyperventilate (goal ETCO2 of 30-35 mmHg)
    • If heart block or post heart transplant, apply transcutaneous pacer (see below)
    • If toxin ingestion, see specific toxin
  • In an infant (< 1 year) initiate chest compressions if heart rate remains slower than 60 beats per minute despite oxygenation and ventilation
  • If signs of severe cardiopulmonary compromise persist (use first available route):
    • Epinephrine (1:10,000) 0.01 mg/kg (Max 1 mg) IV/IO
      OR, if no IV/IOM
    • Epinephrine (1:1,000) 0.1 mg/kg (Max 2.5 mg) diluted in 5 ml of NaCl via endotracheal tube; give 5 manual ventilations after drug administered
      • Repeat dose every 3-5 minutes until either the bradycardia or severe cardiopulmonary compromise resolves
  • If signs of severe cardiopulmonary compromise persist despite Epinephrine:
    • Atropine at 0.02 mg/kg via IV, IO, or Endotracheal tube (if given via ETT dilute in 5 ml of 0.9% NaCl and administer 5 ventilations after drug given)
      • Minimum dose is 0.1 mg; Maximum individual dose is 0.5 mg
      • May repeat once after 3-5 minutes
  • If severe cardiopulmonary compromise persists despite Epinephrine/Atropine apply transcutaneous pacemaker
    • If weight is ≥ 15 kilograms apply adult transcutaneous pacemaker
    • If <15 kilograms use pediatric pads (small/medium electrodes) in the standard configuration for adult size pacer pads
    • Use lowest energy setting that achieves ventricular capture (pulse)
  • Check blood glucose and treat glucose < 70 mg/dl
    • D10W at 5 ml/kg for children < 1 year old (max 40 ml)
    • D25W at 2 ml/kg for children 1-8 years old (max 50 ml)
    • D50W at 1 ml/kg for children ≥ 9 years old (max 50 ml)

Pediatric Bradychardia Flowchart

Tachycardia

Basic Life Support

  • If trauma suspected, stabilize spine
  • Supplemental 100% oxygen

Advanced Life Support

  • Full Pediatric ALS Assessment and Treatment
  • Check blood glucose and treat glucose < 70 mg/dl
    • D10W at 5 ml/kg for children < 1 year old (max 40 ml)
    • D25W at 2 ml/kg for children 1-8 years old (max 50 ml)
    • D50W at 1 ml/kg for children ≥ 9 years old (max 50 ml)

Sinus tachycardia

  • Infants: rate usually <220/min
  • Children: rate usually <180/min
  • Identify and treat possible causes

Supraventricular tachycardia with severe cardiopulmonary compromise

  • Infants: rate usually ≥220/min
  • Children: rate usually ≥180/min
  • If vascular access is available:
    • Adenosine(Adenocard) 0.1 mg/kg (Maximum individual dose 6 mg) IV rapid bolus
    • Repeat Adenosine (Adenocard) twice at 0.2 mg/kg if needed (Maximum individual dose 12 mg)
  • If Adenosine is unsuccessful and patient still has severe cardiopulmonary compromise:
    • Synchronized Cardioversion at 1 J/kg
    • If unsuccessful and severe symptoms persist repeat Synchronized Cardioversion at 2 J/ kg (Maximum individual dose 360 joules)
  • Expedite transport

Ventricular tachycardia with a pulse

  • If the patient is stable provide supportive care and expedite transport
  • If the patient becomes unstable (hypotension and acutely altered mental status):
    • Synchronized Cardioversion at 1 J/kg
    • If unsuccessful and severe symptoms persist repeat Synchronized Cardioversion at 2 J/ kg (Maximum individual dose 360 joules)
  • If Torsades de Pointes is suspected:
    • Magnesium Sulfate 50 mg/kg IV over 5-10 minutes

Pediatric Tachycardia Flowchart