Neonatal Arrhythmia

Birth History• ARB• Delivered via STAT Primary Cesarean Section for arrest in

cervical dilatation • 25 year old G1P1 (1001)• AOG: 38 5/7 weeks• MT: 39 AGA• Apgar Score: 9,9• Anthropometrics:

• BW= 2890 grams• BL= 47 cm• HC= 35 cm• CC= 32 cm• AC= 27 cm

• Maternal History: 1st Trimester, Cough and Colds, no medications given

• Past Medical History: Breast cyst, Left, s/p Excision(2012)

• Family History: Hypertension

• OB History: present pregnancy• Personal Social: College graduate, housewife, no vices

Upon Delivery• Good cry and activity, no cyanosis• Clear amniotic fluid• Flat and open fontanelles• Good air entry, no retractions• Irregular cardiac rhythm, HR 140 bpm, no murmur

(skipped beats, 10 -13x per minute)• Soft Abdomen• Grossly normal female genitalia• Full pulses

Initial Impression

• Term Baby Girl• r/o Cardiac Pathology

PLAN:• Transfer to Level 3 of care hook to cardiac

monitor• Refer to a pediatric cardiologist– Hook to cardiac monitor– BP and oxygen saturations on all extremities

Course in the NICUSubjective Objective Assessment Plan- 3rd HOL- Good suck, cry,

and activity- Able to latch

- T: 36.8, HR 146, RR: 44

- No cyanosis, no alar flaring

- Good air entry, no retractions

- Irregular cardiac rhythm, with 1-2 skipped beats/minute

- Full pulses

Live term baby girlr/o cardiac pathology

- Monitor vital signs every hour

- Hook to cardiac monitor

- BP and O2 sats on all extremities

- Watch out for 25-30 skipped beats/minute

• Stable vital signs• BP on all extremities:

• Oxygen saturations on all extremities: 100%

61/31 63/38

65/30 61/35

Course in the NICUSubjective Objective Assessment Plan- 10th HOL- Good suck, cry,

and activity- Tolerates 10-

15ml of milk feedings

- T: 37, HR 122, RR: 44

- No cyanosis, no alar flaring

- Good air entry, no retractions

- Irregular cardiac rhythm, with 2-5 skipped beats/minute

- Full pulses

Live term baby girlr/o cardiac patholog

- Bed side 2D-echo

- EG-7

• 2D echo– PFO 4.2mm– Left to right shunt– Trivial mitral regurgitation– PDA 1.8 continuous blow– Normal transitional circulation; no arrhythmia

• Cardiology remarks:– Common incidental finding in newborns– Structural abnormality ruled out– No signs of heart failure noted– Refer for >5 skipped beats per minute

• EG7 results:– Na: 138 mmo/L– K: 4.3 mmo/L– iCal: 1.21 mmo/L– Hct: 47%– pH: 7.37– pCO2: 47 mmHg– pO2: 38mmHg (80-105)– HCO3: 27 mmo/L– TCO2: 28 mM– Beecf: 2 mM– sO2: 69% (95-98)– tHB: 16 g/dL

Course in the NICUSubjective Objective Assessment Plan- 24th HOL- Good suck, cry,

and activity- Tolerates 10-

15ml of milk feedings every 2 hours

- T: 36,5, HR 148, RR: 56

- No cyanosis, no alar flaring

- Good air entry, no retractions

- Regular cardiac rhythm, no skipped beats

- Full pulses

Live term baby girl - Rooming in

Course in the NICUSubjective Objective Assessment Plan- Day 2 of life- Good suck, cry,

and activity- Breastfeeding

- T: 36,5, HR 148, RR: 56

- No cyanosis, no alar flaring

- Good air entry, no retractions

- Regular cardiac rhythm, no skipped beats

- Full pulses

Live term baby girl - May go home- For ECG -

Normal

Neonatal Arrhythmias

• Arrhythmias in fetuses and newborns are relatively common -- up to 90% of newborns and 1% to 3% of pregnancies

• Life-threatening arrhythmias are uncommon

• Almost all arrhythmias fall into one of three categories– irregular– tachycardic– bradycardic

• Arrhythmias are found in 1–5% of newborns during the first 10 days of life

• Most are premature supraventricular beats that will disappear during the first month of life

• The development of symptoms depends on the rate and duration of the arrhythmia

• tachyarrhythmia - 240–300bpm• Bradyarrhythmia - <100bpm

Normal Newborn ECG

Sinus Pause

Sinus Arrhythmia

• Sinus pauses from 800 to 1,000 msec may occur in healthy newborns

• Such pauses usually are followed by escape beats from the atria or the atrioventricular (AV) junction

• Pauses of more than 2 seconds are considered abnormal

• Possible causes:– oversedation, (drugs passed through the placenta)– hypothermia– central nervous system abnormalities– increased intracranial pressure– increased vagal tone– obstructive jaundice– hypothyroidism