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Think Fast: Managing Pediatric SVT

It is important to distinguish sinus tachycardia vs SVT, especially in infants and younger children. Sinus tachycardia will typically have a varying heart rate, while SVT is generally steady and unvarying. Another clue to differentiation is if P-waves are visible on EKG, they will be normal and upright in lead I and aVF, while they will be abnormal in SVT.4 Due to baseline elevated heart rates in children, it can often be challenging to appreciate P-waves prior to QRS complexes. A good trick is to increase the speed of the EKG to 50mm/s to reveal P-waves that can get buried in QRS complexes.

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 Supraventricular Tachycardia

What if adenosine didn’t work? This is relatively uncommon… but… Order a clean pair of pants for yourself. Page the Cardiologist. Then order Procainamide. For refractory or recurrent pediatric SVT, procainamide has been shown to be more effective than Amiodarone. Amiodarone may not be as effective as commonly believed. Procainamide 15mg/kg IV over 30-60 minutes And… don’t forget electricity is always an option too!

 The Evaluation And Management of Pediatric Cardiac Tachyarrhythmias: An Evidenced-Based Approach

Adenosine successfully terminates 80 to 95% of episodes of AVRT, which accounts for the majority of SVT in children, and approximately 75% of episodes due to other SVT causes. Early recurrence of the SVT after termination occurs in 25 to 30% of cases. In patients with WPW associated SVT, adenosine can cause atrial fibrillation progressing into ventricular fibrillation. Caution is advised with adenosine administration if WPW is a likely mechanism, and resuscitation equipment should always be available.55 Patients with antidromic SVT may present with a wide-complex tachycardia. If the episode is the first presentation of a regular wide-complex tachycardia, the arrhythmia should be treated as ventricular tachycardia until proven otherwise. Using adenosine in such patient requires close cardiologist involvement.

Articles of Interest

Pediatric Dysrhythmias

Most common are; Sinus Tach -50%, SVT - 13%...

Atrial fibrillation without cardiac anomaly in a 9-year-old child

This case report suggests that when children with narrow-complex tachycardia visit the emergency department, the possibility of AF, in addition to supraventricular tachycardia, should be considered if the RR intervals are markedly irregular.

Common paediatric arrhythmias

SVT is the most common dysrhythmia seen in the paediatric population, and comprises over 90% of paediatric dysrhythmias. Of children presenting with SVT: Half will have no underlying heart disease 1⁄4 will have WPW Almost 1⁄4 will have congenital heart disease

EMS Protocol of the Week - Dysrhythmia (Pediatric)

It may come as a…shock…to you all, but there are some subtle differences here between this protocol and its adult counterpart, so be sure to…slow down…and read through it, carefully? Idk, I’m writing less of these now, I’m rusty.

Paediatric cardiac arrhythmias Guidelines

Resuscitation Council UK guidelines

Pediatric Arrhythmias - atrial fibrillation

Hemodynamically stable children have several treatment options including digoxin, amiodarone, propranolol, esmolol, or procainamide for ventricular rate control. Hemodynamically unstable children need immediate synchronized cardioversion with 0.5 - 1 J/kg. (don't forget light sedation.)

Safety of adenosine for pediatric tachyarrhythmia treatment in the emergency department: a multi-hospital 10-year cross-sectional study

In this study, we found that adenosine treatment in pediatric patients with SVT was safe. This is the largest study of side effects of adenosine in children to date. There were no patients with sustained ventricular tachycardia or prolonged cardiac pauses that required intervention. When excluding undetermined rhythms and atrial fibrillation, the only patients that required electrical cardioversion were those persistently in SVT who then became hypotensive. We discovered that 44% of patients required extra doses, and 22% of patients either required electrical cardioversion or continuous antiarrhythmic medication to maintain sinus rhythm. Adenosine is often thought to induce significant cardiac pause and frequent ventricular beats which may be anxiety-inducing for treating physicians and staff. This study supports the fact that these events are transient and do not require intervention.

Treatment of supraventricular tachycardia in infants: analysis of a large multicenter database

Amiodarone was the most commonly used acute therapy in our cohort. Amiodarone therapy for acute management of recurrent adenosine-refractory SVT in children has been reported previously, including one retrospective study comparing its safety and efficacy to procainamide