APPROACH TO PEDIATRIC ARRHYTHMIAS

ALI M EL-HALABI ,MB,BS,FRCP,FRCPCH

SENIOR CONSULTANT PEDIATRIC CARDIOLOGIST
ELECTROCARDIOGRAM
Waves and
intervals
 How to read ECG
1. Rate
2. Rhythm
3. Axis
4. P wave
5. PR interval
6. QRS complex
7. QT interval
8. ST segment
9. T wave
10. U wave
11. VH
Questions to be answered
• Rapid or slow pulse?
• Continuous or occasional irregularity?
• Rhythmic irregularity or not?
• Healthy, symptomatic?
• Disappears with exercise?
ELECTROCARDIOGRAM
• ? Sinus
• ? Regular
• ?P wave
• ?QRS complex
• ?P-QRS relation
INVESTIGATIONS
• Chest X-ray
• Holter monitor
• Exercise test
• Trans-telephonic monitoring
• Implantable recorder
BENIGN RHYTHM DISTURBANCES
Normal Sinus Rhythm
Pediatric Dysrhythmias

Treatment not required Treatment is required

Sinus arrhythmia Supraventricular tachycardia

Wandering atrial pacemaker

Isolated premature atrial

contractions
Isolated premature ventricular
contractions
First degree AV block
Ventricular tachycardia
Third degree AV block with
symptoms
Benign Arrhythmias

Usually due to Hypervagotonia:

• Sinus arrhythmia
• Sinus bradycardia
• Wandering pacemaker
Sinus Tachycardia
Sinus arrhythmia
Isolated PAC’s
Isolated PAC’s
Sinus Bradycardia
Sinus Pause (Exit Block)
Wandering Pacemaker
Ectopic Atrial Rhythm
Junctional Rhythm
PVC’s

• If unifocal, disappear with exercise, and associated

with structurally and functionally normal heart, then
considered benign, no therapy needed
First Degree AV Block
Second Degree Heart Block

Pacemaker when symptomatic or in infancy

PTHOLOGIC ARRHYTHMIAS
Definition of SVT
• Supraventricular tachycardia is generally
defined as a rapid heart rate resulting
from an abnormal mechanism that
originates proximal to the bifurcation of
the bundle of His
• Presetation very variable depending on
age, frequency, duration……
Different types of Atrial Arrhythmia
(Supraventricular Tachycardia)
• AV reentrant tachycardia

• AV node reentrant tachycardia

• Primary atrial tachycardia

– Atrial flutter
– Atrial fibrillation
– Atrial ectopic
Pre-excitation Mechanism
Case 1-1: 19 Days Old
Case 1 - 12 Leads ECG
Delta Wave in WPWS
Treatment of SVT
Acute management

• Vagal stimulation- valsulva, water bucket, ice

bag
• Adenosine
• ? Verapamil, Digoxin?
• Cardioversion
  QRS Usually Normal
SVT Diagram  Rate Usually > 220 bum
 P wave visible in 50 % of

Acute patients, may be retrograde

 Record 3 Lead ECG during
administration of
medications
Management Oxygen

Unstable Stable
Heart Failure, Hypotension

Cardioversion 0.25-2.0 J/kg Adenosine

Or 50 mcg / kg Rapid IV bolus
Overdrive pacing Double dose up to 400mcg/kg
Obtain 12 Lead ECG i.e. 100, 200, 400mcg

No conversion No conversion Rhythm

Unstable Stable Conversion

Check Diagnosis
Consult Pediatric Cardiologist

Other Options
Vagal maneuvers
Esmolol 100-500 mcg/kg/min X 2 min then 50 mcg/kg/min OR
Propranolol (0.5 mg/kg)
Procainmide 2 mg/kg X 5 min then 50 mcg/kg/min
Verapamil 0.1 mg/kg (contraindicated in infants)
Amiodaron

Prepared by: Dr. Riyadh M. Abu-Sulaiman 1422

Diving reflex
• safe and successful technique for termination
of re-entrant forms of SVT.
• The diving reflex results in increased
parasympathetic tone to the heart
• Cold water-ice to the face.
• Immersion of head into basin of ice and water.
Radiofrequency Ablation

RA

RF
Catheter

RV
Treatment of SVT
After the attack
( Do we need to treat & how long???)
• Digoxin
• B- blockers
• Flecainide
• Amiodarone
• Verapamil
• Others
• Ablation
Atrial Flutter
Atrial fibrillation with rapid ventricular response
COMPLETE HEART BLOCK
COMPLETE HEART BLOCK

Prolonged QT + PVC
QTc = QT / √RR
Ventricular Tachycardia
• Isolated PVC, couplets and non-sustained
ventricular tachycardia
– No heart disease > Favorable prognosis
• Vent. arrhythmias resolve first month age
• Sustained vent. arrhythmias associated with
ischemia, myocarditis or ventricular tumors
associated with a guarded prognosis
Case 12: 2 Days old girl
THANK YOU