Department of Pediatrics Division of Pediatric Emergency Medicine State University of New York at Buffalo November 13 2013 PEMCoR 20132014 091813 Hypovolemic amp Distributive Shock 103013 Cardiogenic amp Obstructive Shock ID: 778944
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Slide1
PEM|COR: Tachycardia
Frank P. Carnevale, M.D.
Department of Pediatrics
Division of Pediatric Emergency Medicine
State University of New York at Buffalo
November 13, 2013
Slide2PEM|CoR: 2013-2014
09-18-13: Hypovolemic & Distributive Shock
10-30-13: Cardiogenic & Obstructive Shock
11-13-13: Tachycardia
01-29-14:
Bradycardia
02-12-14: Fever Work-up
03-19-14: ATLS
& RSI
Issues
04-30-14: Cardiac Arrest
05-07-14: Neonatal Resuscitation
Slide3Learning Objectives
Differentiate SVT from ST
Recognize and manage pediatric tachycardia with a pulse and adequate vs. poor perfusion
Describe how and when to use
vagal
maneuvers, adenosine, and synchronized
cardioversion
for the treatment of SVT
Slide4The sequel to the Halloween Candy Monster (2013)…
http://
youtu.be/RK-oQfFToVg
Slide5Learning Objectives
Differentiate SVT from ST
Recognize and manage pediatric tachycardia with a pulse and adequate vs. poor perfusion
Describe how and when to use
vagal
maneuvers, adenosine, and synchronized
cardioversion
for the treatment of SVT
Slide6Normal Heart Rate
(per minute)
Age
Awake Rate
Sleeping Rate
0 to 3 months
85 to 205
80 to 160
3 months to 2 years
100
to 190
75 to 160
2 to 10 years
60 to 140
60 to 90
> 10 years
60 to 100
50 to 90
Slide7Tachyarrhythmias
Tachycardia is a HR that is fast compared with the normal HR for the child’s age
Sinus Tachycardia is a normal response to stress or fever
Tachyarrhythmias
are fast abnormal rhythms originating in the atria or ventricles
Tachyarrhythmias
can be tolerated without symptoms for a variable amount of time
They can then cause acute hemodynamic compromise from shock to cardiac arrest
Slide8Calculation for cardiac output?
HR x BP
BP x CVP
MAP - ICP
HR x SV
SV x MAP
20
Slide9Coronary perfusion occurs…
Mostly during systole
Mostly during diastole
About equally during systole and diastole
Only during inspiration
Only during expiration
20
Slide10Effect on Cardiac Output
CO = HR
x
SV
Increase HR and you increase CO (to a point)
You reach a point when diastole is so short that the heart doesn’t have time to fill
When end-diastolic filling time decreases, SV decreases and therefore CO decreases
Also, coronary perfusion occurs during diastole, so this can be compromised
This, along with increased metabolic demand from tachycardia can lead to
cardiogenic
shock
Slide11One tiny box on an EKG = ____sec
0.2
0.02
0.1
0.03
0.04
20
Slide12Definition of wide QRS complex?
> 0.09 sec
> 0.07 sec
> 0.12 sec
< 0.1 sec
< 0.2 sec
20
Slide13Wide QRS seen in:
Sinus
Tach
SVT
VT
Atrial flutter
A fib
20
Slide14Tachyarrhythmias:
Narrow vs. Wide QRS complexes
Narrow Complex (<
0.09 second)
Wide Complex (> 0.09 second)
Sinus Tachycardia (ST)
Ventricular Tachycardia (VT)
Supraventricular
tachycardia
(SVT)
SVT with aberrant
intraventricular
conduction
Atrial
Flutter
Slide15Sinus Tachycardia
A sinus node discharge rate faster than normal for a child’s age
Typically develops in response to body’s need for increased
cardiac output
Common causes: exercise, pain, anxiety, tissue hypoxia,
hypovolemia
, shock, fever, metabolic stress, injury, toxins, and anemia
Slide16ST has beat-to-beat variability.
True
False
20
Slide17In ST, P waves are present and normal in appearance.
True
False
20
Slide18ECG characteristics of ST:
PR normal; R-R constant
PR normal; R-R variable
PR variable; R-R constant
PR variable; R-R normal
20
Slide19ECG Characteristics of ST
Heart Rate
Beat-to-beat
variability with changes in activity or stress level
Infants < 220
bpm
Children < 180
bpm
P waves
Present/normal
PR interval
Constant, normal duration
R-R interval
Variable
QRS complex
Narrow (<0.09 second)
Slide20Sinus Tachycardia on monitor
http://youtu.be/0Uy8TVGoNjo
Slide21Supraventricular Tachycardia
(SVT)
An abnormally fast rhythm originating above the ventricles
Most commonly caused by a reentry mechanism that involves an accessory pathway
The most common tachyarrhythmia that causes cardiovascular compromise during infancy
Slide22SVT: Clinical Presentation
A rapid, regular rhythm that appears abruptly and may be episodic
In infants, often diagnosed when symptoms of CHF develop
Infants: irritability, poor feeding, rapid breathing, unusual sleepiness, vomiting, and pale, mottled, gray, or cyanotic skin
Older children: palpitations, SOB, chest pain, dizziness, light-headedness, syncope
Slide23Which is incorrect about SVT?
Lack of beat-to-beat variability
HR usually >240
P waves absent/abnormal
R-R interval constant
QRS < 0.09
20
Slide24SVT: ECG Characteristics
Heart Rate
No
beat-to-beat
variability with changes in activity or stress level
Infants > 220
bpm
Children > 180
bpm
P waves
Absent or abnormal (may appear
after the QRS complex)
PR interval
Because
P waves are usually absent, PR interval cannot be determined
R-R interval
Constant
QRS complex
In
over 90% of children, usually narrow (<0.09 second);
wide complex is uncommon
Slide25SVT on monitor
http://youtu.be/ReJo4aclOw8
Slide26ST vs. SVT
Characteristic
ST
SVT
History
Gradual onset;
Hx
of
pain, fever, dehydration, hemorrhage, etc.
Abrupt onset
/ termination/both; Infant- CHF; Child-palpitations
Physical exam
Signs of underlying cause
of ST (fever,
hypovolemia
)
Signs of CHF
Heart rate
Infant: < 220 bpmChild:
< 180 bpm
Infant: > 220 bpmChild: > 180 bpmMonitor
Variability in HR with changes in activity/stim.No variabilityECG
P waves present/normal/upright in I/aVFP waves absent/abnormal/inverted in II/III/
aVF
, following
QRS
Chest x-ray
Small heart, clear lungs
Signs
of CHF (enlarged heart,
pulm
edema)
Slide27Learning Objectives
Differentiate SVT from ST
Recognize and manage pediatric tachycardia with a pulse and adequate vs. poor perfusion
Describe how and when to use
vagal
maneuvers, adenosine, and synchronized
cardioversion
for the treatment of SVT
Slide28Treatment for Sinus
Tach
?
Fluids
Antipyretics
Search for and treat cause
Propranolol
Hyperventilation
20
Slide29Initial treatment for stable SVT?
Adenosine
Cardioversion
Defibrillation
Amiodarone
Vagal maneuvers
20
Slide30Initial treatment for stable VT?
Defibrillation
Vagal
manuevers
Procainamide
Atropine
Cardioversion
20
Slide31Initial
tx
for unstable VT?
Defibrillation
Epinephrine
Amiodarone
Cardioversion
Adenosine
20
Slide32Initial
tx
for unstable SVT?
Defibrillation
Cardioversion
Amiodarone
Vagal maneuvers
Adenosine
20
Slide33PALS Tachycardia Algorithm.
Copyright © American Heart Association
Slide34Learning Objectives
Differentiate SVT from ST
Recognize and manage pediatric tachycardia with a pulse and adequate vs. poor perfusion
Describe how and when to use
vagal
maneuvers, adenosine, and synchronized
cardioversion
for the treatment of SVT
Slide35Vagal Maneuvers
The HR decreases when the
vagus
nerve is stimulated by slowing conduction through the AV node
If child stable, may repeat once
If child unstable, may try these while preparing for pharmacologic or electrical
cardioversion
Infant: Bag of ice/water to the upper face for 15 seconds (don’t occlude nose or mouth)
Older child:
Valsalva
by blowing through an occluded or very narrow straw
Slide36Adenosine
Drug of choice for treatment of SVT
Acts at AV node to block conduction for 10 sec
Common pitfall: drug administered too slowly or with and inadequate IV flush
2-syringe technique
A 10 sec period of
asystole
,
brady
, or 3
rd
degree block may follow administration
1
st
dose 0.1mg/kg (max 6 mg) IV/IO
2
nd dose 0.2mg/kg (max 12 mg) IV/IO
Slide37Synchronized Cardioversion
Defibrillators can deliver unsynchronized and synchronized shocks
Unsynchronized: shock delivered any time during the cardiac cycle; used for defibrillation because there is no organized QRS
Synchronized: used for
cardioversion
from SVT and VT with a pulse; shock delivery is timed to coincide with the R wave of the QRS; goal is to prevent VF that results when you shock during the T wave
Slide38Cardioversion Pitfalls
Must select sync mode prior to EACH charge
If using paddles, must press both buttons simultaneously
When you press shock button, the unit may seem to pause before delivering shock (while waiting for capture)—keep holding down the buttons (if paddles) until shock delivered
If the R waves are low amplitude, may need to increase the gain or select a different ECG lead to achieve capture
Slide39Learning Objectives
Differentiate SVT from ST
Recognize and manage pediatric tachycardia with a pulse and adequate vs. poor perfusion
Describe how and when to use
vagal
maneuvers, adenosine, and synchronized
cardioversion
for the treatment of SVT
Slide40Let’s practice some scenarios with the PEM Fellows
Station #1:
Huma
Station #2: Jeremy
Station #3: Jen
Station #4: Tara
Station #5: Meghan
Station #6: Danielle