Pediatric:

Unstable Tachycardia

 

History:

 

  • Past medical history
  • Medications/toxic ingestion
    • Aminophylline
    • Diet pills
    • Thyroid supplements
    • Decongestants
    • Digoxin
    • Drugs (nicotine/cocaine)
  • Congenital heart disease
  • Prior history of tachycardia
  • Syncope/near syncope
  • Respiratory distress

 

Significant findings:

 

  • Heart Rate
    • Child >180/bpm
    • Infant >220/bpm
  • Pale/cyanotic
  • Diaphoresis
  • Tachypnea
  • Unresponsive
  • Hypotension

 

Differential:

 

  • Congenital heart disease
  • Hypo/hyperthermia
  • Hypovolemia/anemia
  • Electrolyte imbalance
  • Anxiety/pain/emotional stress
  • Fever/infection/sepsis
  • Hypoxia
  • Hypoglycemia
  • Medication/toxin (see History)
  • Pulmonary embolus
  • Trauma
  • Tension pneumothorax

 

 Treatment:

 

  • Oxygen
  • 12-Lead EKG
  • Initiate IV/IO
  • May attempt valsalva maneuver (ice or cold rag to patient's face)

 

Narrow QRS (<0.08) ?

 

  • Yes

 

    • Strongly rule out differential diagnosis (i.e., postictal, fever, etc.)

 

 

 

 

 

Wide QRS (>0.08) ?

 

  • Yes

 

 

 

    • Notify receiving facility or contact Medical Control

 

PEARLS:

 

  • Pediatric = 1 day to less than age 12, or less than 55 kg in ages 12-18.
  • Use Handtevy for drug dosages.
  • Carefully distinguish sinus tach, SVT, and V-tach. Rule of thumb: the maximum sustainable sinus tach rate is 220 minus the patient's age in years.
  • Tachycardia in pediatrics is normally caused by hypoxia or hypovolemia. Identify and treat underlying causes.
  • For conscious sedation administer Midazolam (Versed) 2.5 mg/0.5 mL IM if less than 13 kg; if greater than 13 kg administer Midazolam (Versed) 5 mg/1 mL IM; if IV obtained, adminster Lorazepam (Ativan) 0.1 mg/kg IV; max 2 mg.
  • Separating the child from the caregiver may worsen the child's clinical condition.
  • Pediatric paddles should be used in children less than 10 kg or Broselow color purple.
  • Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.