arrhythmias – clinical features
TRANSCRIPT
Arrhythmias: Bland & the Nasty
Approach to Childhood Arrhythmias
• Tachyarrhythmias– Classification– Diagnostic approach– Immediate treatment strategies
Long term management of tachyarrhythmias
Bradyarrhythmias
Arrhythmias: Bland & the Nasty
Classification of tachycardia
• conventional SVT / VT
• electrophysiological re-entry / automatic• appearance normal QRS / wide QRS
• age infancy / childhood• behaviour paroxysmal / incessant
• structural normal / post-op
• significanceBland / nasty
• substrate e.g. accessory connection
• Mechanism e.g. orthodromic AV re-entry
Non invasive diagnosis of tachycardia
Arrhythmias: Bland & the Nasty
Typical responses!
Panic is an unnecessary and inappropriate response because most childhood arrhythmias are associated
with stable hemodynamics
Arrhythmias: Bland & the Nasty
Arrhythmia Management: Basic Rule
• Diagnosis before treatment • A variety of incorrect practices in
management of arrhythmias result from a failure to respect this simple rule
Unless it is an emergency resist the urge to treat the arrhythmia before being sure what it is!
Arrhythmias: Bland & the Nasty
Diagnostic Approach for Tachyarrhythmias
Traditional Classification
Narrow QRS
Usually stable hemodynamics
Supraventricular
Broad QRS
Often unstable hemodynamics
Ventricular /supraventricular
Arrhythmias: Bland & the Nasty
1 : 1 A V B
r e g u l a r i r r e g u l a r
n o r m a l Q R S
L B B B R B B B n e i t h e r
r e g u l a r i r r e g u l a r
w i d e Q R S
t a c h y c a r d i a
Diagnosis of tachycardia
Classification of tachycardia
Arrhythmias: Bland & the Nasty
Diagnosis of tachycardia
essential information
• history - age of onset, symptoms, etc• ECG in tachycardia• ECG in sinus rhythm
• ECG with adenosine administration
Arrhythmias: Bland & the Nasty
Irregular heart beatInappropriate heart rate for the situationUnexplained CHFDiseases associated with arrhythmiasSyncope/palpitationsFamily history
Arrhythmias – clinical features
Arrhythmias: Bland & the Nasty
Arrhythmias: The First Step
• Connect the child to an ECG machine
• Get a 12 lead ECG
• If the child is uncooperative, at least get the limb leads
Arrhythmias: Bland & the Nasty
The Monitor Can Mislead
• Single non-standard lead• P waves are not often clearly seen
• Interpretation of QRS morphology• Regular vs. Irregular rhythm• Difficult to document response to
intervention
Arrhythmias: Bland & the Nasty
ECG analysis - normal QRS
• are the QRS complexes regular?• are P waves seen?• what is the AV or VA relationship?• where is the P wave in the RR interval?
Non invasive diagnosis of tachycardia
Arrhythmias: Bland & the Nasty
Narrow QRS Tachycardia
Irregular• Atrial fibrillation• Multifocal or chaotic
atrial tachycardia• Flutter with varying
conduction
Regular• Sinus tachycardia• Atrial Flutter• AV nodal re-entrant
tachycardia• Tachycardias based
on bypass tracts
•Ectopic atrial tachycardia•Junctional ectopic tachycardia
Arrhythmias: Bland & the Nasty
Arrhythmias: Bland & the Nasty
Irregular Narrow QRS Tachycardia
Arrhythmias: Bland & the Nasty
Fast AF in patient with ASD
Arrhythmias: Bland & the Nasty
Irregular Narrow QRS Tachycardia
MAT
Ectopic atrial tachycardia
A Flutter with varying conduction
Arrhythmias: Bland & the Nasty
P wave morphology
I
II
III
Arrhythmias: Bland & the Nasty
12 Lead ECG: P-QRS Relationship
A-V dissociation: JET
Arrhythmias: Bland & the Nasty
Sinus Tachycardia
Arrhythmias: Bland & the Nasty
Sinus Tachycardia: A Cause Can Almost Always be Found
• Anxiety
• Fever
• Hypovolemia
• Hyperthyroidism
• Bronchodilators
Arrhythmias: Bland & the Nasty
Sinus Tachycardia: In the ICU
• “Light” sedation
• Inotropes and chronotropes
• Low output
• Fever (rectal temp)
• Hypovolemia
Arrhythmias: Bland & the Nasty
Sinus Tachycardia
• Rates can be as high as 240/min
• Subtle variations in rate
• Treating cause brings down the rate
• When in doubt: 12 lead ECG
• If doubts persist: adenosine
Arrhythmias: Bland & the Nasty
Narrow QRS Tachycardia: P Waves are not always Seen…..
Arrhythmias: Bland & the Nasty
Diagnosis of tachycardia
Recording response to adenosine
•Ultra short acting
•Blocks conduction across the AV node
•Terminates tachyarrhythmias where AV node is a part of the circuit
•Temporarily slows heart rates if circuit above AV node
Arrhythmias: Bland & the Nasty
Administering Adenosine
Adenosine 50-200 mcg/kg, fast push
Saline bolus, fast push
Reliable proximal IV line
10 cm extn.
Arrhythmias: Bland & the Nasty
Arrhythmias: Bland & the Nasty
Stable Narrow QRS tachycardiaAdenosine 140 mcg/kg bolus
Sudden termination
AVNRTAVRT
Slow and unmask
Flutter,ectopic atrial
tachy
No effect
Sinus tachy,Junctional ectopic
tachycardia
Arrhythmias: Bland & the Nasty
AV nodal re-entrant tachycardia: Sudden termination with adenosine
Response to Adenosine
Tachycardia Sinus
Arrhythmias: Bland & the Nasty
Response to Adenosine
Tachyarrhythmia after Senning + Rastelli (LTGA, VSD, PS)
Surface
Atrial
Atrial
Abrupt restoration to Sinus Rhythm after adenosine
Arrhythmias: Bland & the Nasty
Response to Adenosine
Narrow QRS tachycardia @ 200/min
Unmasking of atrial activity (Flutter waves)
Arrhythmias: Bland & the Nasty
Alternatives to Adenosine
• Ice bag on face; effects similar to adenosine• Older children and teens:
– Carotid sinus massage, supine valsalva
– Verapamil 0.1 mg / kg slow (only for narrow QRS tachycardias
• Cardioversion: Synchronized DC shock - 0.5 – 1 J/kg. First line for unstable narrow QRS tachycardia
Arrhythmias: Bland & the Nasty
Response to DC Shock
Responders: all re-entrant arrhythmias
A Flutter, AVRT, AVNRT, reentrant VT
Non-responders: all tachycardias based on automatic foci
JET, EAT, Sinus tachycardia, MAT
Arrhythmias: Bland & the Nasty
After the Event: ECG in Sinus Rhythm
Arrhythmias: Bland & the Nasty
Failure of the tachycardia to terminate after adenosine
Cardioversion
Ectopic atrial Tachycardia
Flutter
Sinus Tachycardia
Beta BlockadeDigoxin
Amiodarone
Digoxin, Betablockade
Rarely Amiodarone
Treat the Cause
Arrhythmias: Bland & the Nasty
Tachycardiomyopathy
• Certain incessant tachycardia in children can present clinically with heart failure and LV dysfunction like “myocarditis or DCM”
• Permanent Junctional Re-entrant tachycardia: RF ablation
• Ectopic atrial tachycardia: Antiarrhythmic medications / RF ablation
Arrhythmias: Bland & the Nasty
ECG analysis - wide QRS
• what is the QRS morphology in sinus rhythm?• is the QRS pattern LBBB, RBBB, pre-excited,
other?• are the QRS complexes regular?• are P waves seen?• what is the AV / VA relationship?
Non invasive diagnosis of tachycardia
Arrhythmias: Bland & the Nasty
Arrhythmias: Bland & the Nasty
Arrhythmias: Bland & the Nasty
Arrhythmias: Bland & the Nasty
Arrhythmias: Bland & the Nasty
TORSADES DE POINTES
Arrhythmias: Bland & the Nasty
Wide QRS tachycardia
Stable Unstable
DC shockIf 1:1 P-QRS relation, try adenosine
If AV dissociation, IV Lignocaine 1 mg/kg or IV amiodarone 5 mg/kgIf no response, DC shock CPR
Arrhythmias: Bland & the Nasty
Unstable Wide QRS Tacharrhythmia
• VT• Synchronized DC
shock 0.5-2 J/kg
• VF• Unsynchronized
DC shock 2-4 J/kg
Arrhythmias: Bland & the Nasty
ECG After the Event……..
Long QT syndrome
Arrhythmias: Bland & the Nasty