Pediatrics ECG Monitoring

Pediatric Intensive Care Unit

Emergency Division

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Conditions Leading to Pediatric Cardiology Consultation

12.7% of

Geggel. Pediatrics. 2004; 114: e409-17

12.7% of

annual consultation

Is arrhythmias

problems

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Arrhythmias of hospitalized children

Irusta et al. Com Cardiol. 2006; 33: 609-113

Lead Placement

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Three channels system

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Arrhythmias Mechanisms

• Abnormal Impulse Initiation– Automaticity

• Normal automaticity• Abnormal automaticity

– Triggered Activity• Early afterdepolarizations• Delayed afterdepolarizations• Delayed afterdepolarizations

• Abnormal Impulse Conduction– Conduction block leading to ectopic pacemaker "escape"– Unidirectional block & reentry

• Ordered reentry: functional anisotropic, anatomical• Random reentry

• Simultaneous Abnormalities of Impulse Initiation and Conduction– Parasystole

Janse et al. 1993 6

Tachyarrhythmias Classification

• Narrow QRS complex– Regular

• Atrioventricular Reciprocating Tachycardia (AVRT)

• Atrioventricular Nodal Reentrant Tachycardia (AVNRT)

• Atrial Flutter (AFL)

• Atrial Tachycardia (AT)

• Junctional Tachycardia (JT)

• Narrow complex Ventricle Tachycardia

– Irregular• Sinus Arrhythmia• Sinus Arrhythmia

• Atrial Fibrillation

• AFL or AT with varying AVN conduction

• Wide QRS complex– Ventricle Tachycardia (VT)

– Supraventricle Tachycardia (SVT) with bundle branch block (BBB)• Abberancy

• Pre-existing BBB

– SVT with pre-excitation• Antidromic AVRT

• AVNRT with pre-excitation

• AFL or AT with pre-excitation7

Supraventricular Tachycardia (SVT)

AVNRT AVRT8

Introduction

• Supraventricular tachycardia (SVT)

– Cardiovascular emergency in infant and

children

– The incidence: 1/25,000-1/250 – The incidence: 1/25,000-1/250

– Early detection and prompt treatment

important

• Congestive heart failure

• Circulatory arrest

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Causes :

1. No heart disease is found in about half of patients.This idiopathic type of SVT occurs more commonly in young infantsthan in older children

2. WPW syndrome is present in 10% to 20% of cases and is evident onlyafter conversion to sinus rhythmafter conversion to sinus rhythm

3. Some congenital heart defects (e.g eibstein’s anomaly, single ventricle,congenitally corrected transposition of the great arteries) are more proneto this arrhythmia

4. SVT may occur following cardiac surgeries

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Classification of SVTClassification of SVT

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SVTSVT

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SVTSVT

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Clinical Manifestation

• Clinical manifestation of SVT

–Infants

–Children–Children

–SVT chronic

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Clinical Manifestation

• SVT in infants

– Irritability

– Feeding problem

– Tachypneu– Tachypneu

– Pale

– Vomit

– Heart rate: 200-300 times/minutes

– Heart failure

– Circulatory arrest15

Clinical Manifestation

• SVT in Children

–Sign and symptom less severe then

infant

–Rare to have heart failure/circulatory

arrest

–Symptom: palpitation/chest discomfort

–Heart rate < SVT in infants

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Clinical Manifestation

• SVT chronic

–SVT long lasting: week-months

–HR < SVT infant or children–HR < SVT infant or children

–Symptom influenced by

autonomic nerve system

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Short-Term management

of SVT

Delacretaz. NEJM 2006;354:1039-51

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Management :

1. Vagal stimulatory maneuvers (carotid sinus massage, gagging, pressure

on an eyeball) may be effective in older children but are rarely affective

in infants

2. Placing an ice bag on the face (for up to 10 seconds) is often effective

in infants

3. Adenosine (an endogenous nucleoside, negative chronotropic, dromotropic,

an inotropic actions of very short duration (half life <1.5 second), with an inotropic actions of very short duration (half life <1.5 second), with

minimal hemodynamic consequences

Dose : 50 μg/kg and increasing in increments of 50 μg/kg every 1 to 2 minutes

(max 250 μg/kg)

effective dose : 100 to 150 µg/kg

4. Cardioversion 0,5 joule/kg, may be increased in steps up to 2 joule/kg

5. Digitalization

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6. Intravenous infusion of phenyleprine

7. Intravenous administration of propranolol or verapamil

(not treatment of choice)

8. Intravenous amiodarone (postoperative atrial tavhycardia)

9. Transesophageal pacing in ICU or by atrial pacing in the cardiac cath lab

10. Recurrence of SVT should be prevented with a maintenance dose of10. Recurrence of SVT should be prevented with a maintenance dose of

digoxin for 3 to 6 months

11. Radiofrequency catheher ablation

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Radiofrequency Catheter Ablation

• Used a definitive therapy since 1989

• Using intracardiac catheters, radiofrequency energy is used to desiccate a small, well-circumscribed area of cardiac circumscribed area of cardiac tissue thought to be essential to the arrhythmia circuit, such as the accessory connection

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Radiofrequency Catheter AblationRadiofrequency Catheter Ablation

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Radiofrequency Catheter AblationRadiofrequency Catheter Ablation

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• Success rate: 90-98%

• Recurrent rate: 2-5%

• Difficulties: 1%

Radiofrequency Catheter Ablation

• Difficulties: 1%

• Currently Radiofrequency ablation catheter is

the first line treatment rather than chronic

medical treatment

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Sudden Cardiac Death in Wolf-

Parkinson-White Syndrome

• 0.15-0.39% over 3-10 years follow-up

• 50% cardiac arrest in WPW: first

manifestationmanifestation

• High incidence of SCD in familial WPW

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WPW with AF

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Recommendations for Acute Management of

Hemodynamically Stable and Regular Tachycardia

ECG Recommendation* Classification Level of Evidence

Narrow QRS Vagal maneuvers I Btachycardia Adenosine I A(SVT) Verapamil, diltiazem I A

Beta blockers IIb CAmiodarone IIb CDigoxin IIb C

Wide QRStachycardia•SVT and BBB See above•Pre-excited SVT/AF† Flecainide I B

Ibutilide I BIbutilide I BProcainamide I BDC cardioversion I C

•Wide QRS-complex Procainamide I Btachycardia of Sotalol I Bunknown origin Amiodarone I B

DC cardioversion I BLidocaine IIb BAdenosine§ IIb C

Beta blockers III CVerapamil III B

Wide QRS Amiodarone I Btachycardia, DC cardioversion, I BUnknown origin, lidocainepoor LV function 28

Typical Atrial Flutter

IIII

V1

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2:1 Atrial Flutter

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Atrial flutterArial Flutter

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• Characterized by an atrial rate (F wave with “sawtooth”

configuration) of about 300 beats/minute

• A ventricular response with varying degrees of block

• Normal QRS complexes

CausesCauses

-Structural heart disease with dilated atria, myocarditis,previous

surgery involving atria (Mustard or Senning procedure, Fontan

operation, or ASD repair) and digitalis toxicity

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Acute Management of Atrial Flutter

Clinical Status/ Level of

Proposed Therapy Recommendation* Class EvidencePoorly tolerated

•Conversion DC cardioversion I C

•Rate control Beta blockers IIa C

Verapamil, diltiazem IIa C

Digitalis IIb C

Amiodarone IIb C

Stable flutter

•Conversion Atrial or transesophageal pacing I A •Conversion Atrial or transesophageal pacing I A

DC cardioversion I C

Ibutilide IIa A

Flecainide IIb A

Propafenone IIb A

Sotalol IIb C

Procainamide IIb A

Amiodarone IIb C

•Rate control Diltiazem, verapamil I A

Beta blockers I C

Digitalis IIb C

Amiodarone IIb C

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What is the appropriate

dosage?

www.ucsf.org 34

Class Channel effects Repolarization

time

Drug examples

IA Sodium block effect ++ Prolongs Quinidine

Disopyramide

Procainamide

IB Sodium block effect + Shortens Lidocaine

Phenytoin

Mexiletine

Tocainide

Ethmozine

IC Sodium block effect +++ Unchanged Flecainide

Antiarrhythmic drug class

IC Sodium block effect +++ Unchanged Flecainide

Encainide

Propafenone

Indecainide

Ethmozine

II Phase IV (depolarizing

current);calcium channel

Unchanged Β-blockers

III Repolarizing K+ currents Markedly prolongs Amiodarone

Sotalol

Bretylium

IV Calcium block effect ++

K+ channel openers

(Hyperpolarization)

Unchanged

Unchanged

Verapamil, diltiazem

Adenosine, ATP

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