Arrythmias by A Scuola di Salute

Arrythmias

Objectives

At the end of this session, participants will be able to: • Recognize the main cardiac arrythmias • Know the specific algorithms

Arrythmias

General Assessment: Arrythmias

Is the pulse present? No Cardiac arrest algorithm

Arrythmias

Cardiac arrest algorithm

Arrythmias

Heart rate rapid assessment

Arrythmias

Does the child have a pulse?

If absent, arrest lgorithm If present, slow or fast?

Is the patient stable or in shock?

Assess the presence/absence of central and peripheral pulses, skin color, temperature, capillary refilling, consciousness, diuresis, BP, and tachy/bradypnea

Is heart rate high or low?

< 1 year < 180 > 80

Is the rate regular or irregular?

RR distance and QRST sequence

Are P waves visible and regular, and are they responsible of the induction of QRST complexes?

Evaluation of the sinus progression of the cardiac stimulus to identify any conduction abnormalities

In the presence of tachycardia, are the complexes narrow or wide?

Narrow complexes < 0,080 sec atrial Wide complexes > 0,080 sec ventricular

> 1 year < 160 > 60

Slow heart rate: Bradycardia

• Sinus bradycardia • Sinus node arrest • AV block To be treated if associated or causing: • Hypotension and/or shock • Reduced tissue perfusion • Altered consciousness • Sudden collapse

Arrythmias

Bradycardia algorithm

Arrythmias

Medications

• Adrenaline 0,01 mg/kg (IV/IO) every 3-5 minutes • Adrenaline 0.1mg/kg (ETT) • Atropine 0.02 mg/kg (IO/IV) • Atropine 0.4 – 0,06 mg/kg (ETT)

Arrythmias

Rapid heart rate: Tachycardia

Wide complexes: • VT and SVT with aberrant conduction Narrow complexes: • Sinus tachycardia, SVT and atrial flutter To be treated if associated or causing: • Hypotension and/or shock • Reduced tissue perfusion • Altered consciousness • Sudden collapse

Arrythmias

Tachycardia algorithm

Arrythmias

Vascular accesses

Vascular access (IV or IO) is the preferred route of drug delivery during CPR (unchanged from 2005) The intraosseous route is rapid, safe, acceptable and effective as an initial vascular access in case of arrest (class I LOE C) If vascular access is unavailable, fat-soluble drugs (adrenaline, lidocaine, naloxone) can be administered by the endotracheal route (unchanged)

Arrythmias

Fluid and drug administration

Dose calculation • If the weight of the child is not known, it is reasonable to use a tape with doses pre-calculated according to the length (class IIa LOE C) • There is no evidence that the dose should be adjusted in obese children according to the weight • In any case, the dose administered should not exceed that recommended for adults

Arrythmias

Drug administration

Adrenaline and amiodarone • Only medications in the cardiac arrest algorithm (unchanged from 2005) Adrenaline: • 0.01 mg/kg (0.1 ml/kg 1:10000) IV/IO • 0.1 mg/kg (.’1 ml/kg 1:1000) ET • Maximum dose 1 mg IV/IO; 2.5 mg ET Amiodarone: • 5 mg/kg repeatable twice up to 15 mg/kg • In bolus in case of arrest, in 20-60’ if perfusion rate

Arrythmias

Drug administration

Recommendation on calcium chloride • The recommendation on calcium chloride precautions in case of arrest is stronger than in the past • Routine use of calcium chloride is not recommended in the absence of documented hypocalcaemia, calcium antagonists overdose, hypomagnesaemia, and hyperkalaemia • Routine use in case of arrest is not indicated and can be harmful

Arrythmias

Other medications Atropine • • • •

0.02mg/kg IV/IO 0.04-0.06 mg/kg ET Minimum dose: 0.1 mg Maximum dose per single dose 0.5 mg

• In symptomatic bradycardia only if increased vagal tone or primary AV block • NOT in the arrest algorithm (unchanged from 2005)

Arrythmias

Other medications Adenosine • 0.1 mg/kg (max 6 mg) • Second dose: 0.2 mg/kg (max 12 mg) • In bolus • In supraventricular tachycardia and in widecomplex tachycardia without cardiopulmonary impairment, if regular rate and monomorphic QRS

Arrythmias

Other medications Procainamide • • • •

15 mg/kg IV/IO Slowly (30-60 minutes) Monitoring ECG and BP Discontinue if QT prolongation or QRS widening > 50% or hypotension • In broad-complex tachycardia without cardiopulmonary impairment • Expert consultation

Arrythmias

Identification and treatment of arrythmias in children

Arrythmias

Bradycardia Key points Algorithm for the treatment of bradycardia with pulse in children

Rate analysis

Identification of hemodynamic instability

Highlight the significance of symptomatic bradycardia in children Arrythmias

Symptomatic bradycardia in children Identify and treat the causes Most common and potentially reversible causes: • hypoxia • hypovolemia • increased vagal tone (unchanged from 2005)

Arrythmias

Treatment of symptomatic bradycardia Algorithm for the treatment of bradycardia with pulse in children

CPR DRUGS

if FC < 60 IV or IO

• Adrenaline 0.01 mg/kg (IV / IO) • (Adrenaline 0.1 mg/Kg ET) • Atropine: 0.02 mg/Kg - min 0.1, max 0.5 mg (child) or 1 g (adolescent)

Arrythmias

Heart rate analysis Tachyarrhythmias atrial ORIGIN ventricular Narrow QRS complexes

• Sinus tachycardia

• Supraventricular tachycardia • (atrial flutter) Wide QRS complexes

• Ventricular tachycardia

QRS >0.09”

• Supraventricular tachycardia with aberrant conduction Arrythmias

Supraventricular tachycardia Key points

• Differential diagnosis with ST (newborn/child) • Hemodynamic tolerance • Adenosine (doses/routes of administration) • Indications for electrical cardioversion

Transesophageal overdrive, other antiarrhythmic drugs

Arrythmias

Ventricular tachycardia Key points

Identification of the rate

QRS >0.09” •

monomorphic VTs

•

polymorphic VTs

•

operated patients

•

drugs

•

long QT

Treatment algorithm

Arrythmias