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Pediatrics
What’s New??
Introduction
• SME video of the month- Dr. Mark Cichon
• Review of pediatric SOP’s
• Scenarios
SME Video
• https://youtu.be/modU0kzoPF0
Pediatric LVADS
• Heart failure afflicts thousands of children and
adolescents every year
• It can occur unexpectedly and often undetected
until its progression is very advanced
Pediatric Heart Failure
• Cause of heart failure in children can include:
o Defect of blood vessels in the head or other parts of the body (AV
malformation) causing similar mixing arterial and venous blood but
outside the heart
o Abnormal heart valves
o Infection
o Pump Failure
o Drugs especially those necessary to treat to other conditions
o Abnormalities in the heart’s electrical system
o Severe chest trauma
o Muscular dystrophy can also cause problems with the heart muscle
Pediatric Heart Failure
• Clinical History
o Neonates and Infants
• Poor feeding
• Tachypnea worsening during feeding
• Poor weight gain
o Older Children
• Fatigue
• Exercise Intolerance
• Dyspnea/Pedal Edema
• Growth Failure
Pediatric LVADs
• VAD support for children lags behind support
options for adults
• Limited number of devices suitable for children for
both short and long term
• Pediatric devices differ significantly from adult
because they must support a wide range of sizes
from newborn to adolescent.
• They must allow for increased circulatory demand
due to growth of child
Pediatric LVADs
• Currently, the Berlin Heart EXCOR VAD is the only
device approved by the United States FDA for the
pediatric patient
• Once medical devices are approved for use in
adults, they can be considered for use in pediatrics
depending on how the device is “labeled”
• Currently approved LVADs in adults have no
restriction specifically outlined for age or size, hence
they can be used in children
Pediatric LVAD’s
Pediatric LVADs
• Options for LVAD support continue to increase for
larger children and adolescents, infants and small
children remain restricted to the Berlin Heart EXCOR
• Studies have shown that small children on the
pediatric heart transplant wait list have the highest
mortality rate because of the fewest VAD options.
Pediatric LVAD
Pediatric CPAP
• Valued therapy in the adult patient
• Rapidly gaining acceptance in the pediatric
population
• Allows for struggling child to convert rapid little “fish
puffs” into fuller breaths with improved gas
exchange
• Sleep apnea and snoring are quite common in
children for which CPAP is the indicated therapy
Pediatric CPAP
• Other Applications Include:
o Bronchiolitis: Studies have indicated the success of CPAP
compared to intubation in treating respiratory failure associated
with bronchiolitis
o Pneumonia: CPAP helps increase lower airway resistance and
relieves fatigued respiratory muscles to restore tidal volume
o Asthma: Forces small bronchioles open and allows for trapped
air to be released from the alveoli. They also allow for continuous
administration of nebulized bronchodilators
o Pulmonary Edema: Usually rare in the pediatric patient and non
cardiac in nature. Complications from toxic inhalation and
carbon monoxide inhalation can result in a non cardiac
pulmonary edema. CPAP may help in fully oxygenating
hemoglobin improving hypoxemia
CPAP
• Applications cont:
o Drowning: The use of CPAP may be considered in submersion injuries.
• Freshwater drownings have pulmonary injuries that are associated
with atelectasis and hypoxia
• Saltwater near drowning are more likely to develop pulmonary
edema from aspirated hypertonic solutions
o CPAP improves oxygenation in both fresh and saltwater drowning patients
who are awake and spontaneous breathing
Pediatric CPAP
• Pediatric CPAP monitoring should include
o Continuous cardiac monitoring
o End tidal CO2 and pulse oximetry
o Frequent assessment of lung sounds, worsening gastric distention and
temperature monitoring
• Signs of Improvement are indicated by
o
o
o
o
o
Improving skin color, mental status
Improvement in respiratory tidal volume, lung sounds
Decrease in respiratory rate, accessory muscle use and retractions
Decrease in anxiety or agitation
Normalizing of heart rate
Pediatric CPAP
• When utilizing CPAP on a pediatric patient, start
with low pressures (5cm H2O).
• Increase in increments of 1 cm of H2O as tolerated
• Recommended maximum CPAP should be 15 cm
H2O for patients less than 12 years of age
• 12 years of age and up, the maximum should be 20
cm H2O
• Valued therapy for treating common causes of
pediatric respiratory distress caused by bronchiolitis,
asthma and pneumonia
ALTE
• Originated in 1986 from the National Institute
Conference on Infantile Apnea
• Intended to replace the term “near miss sudden
infant death syndrome” (SIDS)
• “SIDS” is now Sudden Infant Unexplained Death and
is only determined after autopsy has ruled out other
causes
• A broad range of disorders can present as an ALTE
• For majority of well appearing infants the risk of a
recurrent event or serious underlying disorder is low
ALTE
• By definition, an ALTE refers to a sudden event,
often characterized by apnea or other abrupt
changes in the child’s behavior. Symptoms include
one or more of the following: apnea, change in
color or muscle tone, coughing or gagging.
• These episodes may necessitate stimulation or
resuscitation to arouse the child and initiate regular
breathing.
BRUE
• Replacing the Term ALTE
• Brief Resolved Unexplained Event (BRUE)
• Used to describe an event occurring in an infant
younger than 1 year
• Observer reports a sudden, brief and now resolved
episode of one of the following
o
o
o
o
Cyanosis or pallor
Absent, decreased, or irregular breathing
Marked change in muscle tone
Altered level of responsiveness
• Should diagnosis only when no explanation for
event after a complete assessment
ALTE
• Because not all children are brought in for
evaluation the true incidence of ALTE is unknown
• Most ALTE occurs in children younger than one year
• Peak incidence occurred between one week and
two months of age, with most events occurring in
infants younger than 10 weeks
• Uncovering the cause of the ALTE most important
ALTE
• Those who are at increased risk include:
o
o
o
o
o
Premature infants
Premature infants with RSV infections
Premature infants who undergo general anesthesia
Children who feed rapidly, cough frequently or choke during feeding
Occurs more often in boys than girls
• Studies indicate that infants older than two months
who had an ALTE and those with recurrent episodes
of ALTE’s were more likely to be diagnosed with a
significant disorder
ALTE
• The child exhibits symptoms alone or in combination
including :
o
o
o
o
Apnea
Change in color
Change in muscle tone
Coughing or gagging
• Approximately 50% of these children are diagnosed
with an underlying condition that explains the ALTE
ALTE
• Commonly the etiology found is
o
o
o
o
o
o
o
Digestive (GI) most common up to 50%
Neurologic 30%
Respiratory 20%
Cardiac 5%
Endocrine and metabolic less than 5 %
Child abuse (less than 5%)
Other 2%
• Once etiology is found potential interventions can
eliminate further events
• 50% are idiopathic meaning a specific diagnosis is
never made
Diagnosis made in
Children with ALTE
• Idiopathic approximately
50%
• Gastro Intestinal (50%)
o
o
o
o
Gastroesophageal reflux
Intussusception
Swallowing abnormalities
Gastric Volvulus
• Neurological (30%)
o
o
o
o
o
o
o
Seizure disorder
Febrile seizure
CNS bleeding
Vasovagal reflexes
Hydrocephalus
CNS Infection/Malignancy
VP shunt malfunction
• Respiratory (20%)
o
o
o
o
o
o
Infection
Obstructive sleep apnea
Breath holding
Vocal cord abnormalities
Conditions affecting respiratory
control (prematurity)
Foreign body aspiration
• Cardiac (up to 5%)
o
o
o
o
Arrhythmia: long QT syndrome,
WPW
Congenital heart disease
Myocarditis
Cardiomyopathy
Diagnosis made in
Children with ALTE
• Metabolic Abnormalities 5%
o
o
o
o
o
Inborn errors of metabolism
Endocrine, electrolyte disorders
Other infections
Urinary tract infection
Sepsis
• Other
o
o
Food allergy
Anaphylaxis
• Child Abuse (<5%)
o Munchausen syndrome by
proxy
• Suffocation
• Intentional salt poisoning
• Mediation overdose
• Physical abuse
• Head injury
ALTE
• Description of the event (chief complaint)
o Condition of child: awake, asleep, position of child
• Activity at time of the event
o Feeding, coughing, gagging, choking, vomiting
• Breathing efforts
o None, shallow, gasping, increased effort
• Color
o Pallor, red, purple, blue, peripheral cyanosis, circumoral cyanosis
• Movement and Tone
o Rigid, tonic-clonic, decreased, floppy
ALTE
• Observations of productive cough, vomiting
o Mucus, blood, or noise (silent, cough, gag, wheeze, stridor, crying)
• Duration of the event
o Length of time required to resume breathing and normal behavior or tone
• Interventions
o None, gentle stimulation, blowing in face, vigorous stimulation, mouth to
mouth breathing, CPR by medically trained personnel
• History
o Illness, fever, poor feeding, irritability, lethargy, contact with someone who
is ill
• Medical History
ALTE
PEDIATRIC APPARENT LIFE-THREATENING EVENT (ALTE)
History of any of the following:
 Apnea
 Loss of consciousness
 Color change
 Loss of muscle control
 Episode of choking or gagging
Important information to relay to Medical Control and document:
 Parental / caregiver actions at the time of the event
 What resuscitative measures were taken
The typical age for such events is 2 years or less, and is most commonly seen in
infants under 12 months. An ALTE is an event that is frightening to the observer and
usually involves some combination of the above symptoms. It may present as a
symptom of a variety of pediatric conditions including seizures, upper airway
compromise, gastroesophageal reflux, metabolic problems, anemia and cardiac
disease.
BLS/ALS
1. Pediatric Initial Medical Care SOP, p. 79
 Support ABC’s
 Perform a complete secondary assessment including:
 General appearance
 Work of breathing
 Circulation to skin
 Evidence of trauma
 Extent of interaction with the environment
 NOTE: Exam may be normal by the time of patient contact with EMS
 Treat any reversible causes identified, including blood glucose abnormalities,
per appropriate SOP
 All ALTE patients should be transported for medical evaluation, even the
well appearing child
2. Transport
 Support ABCs
 Observe
 Keep warm
Munchausen by Proxy
• Is characterized by feigning or intentionally
producing physical and emotional symptoms in
another person to place that person in a sick role. It
is considered a mental illness and a form of child
abuse
Munchausen by Proxy
• Occurrence is very underestimated and can be
completely missed
• Males are victims as often as females
• Caregivers are primarily women
• Caregiver is vulnerable and may suffer from anxiety,
depression and personality disorders
• Caregiver may have history of losing a parent or
being abused and neglected as a child
• Caretaker may have trouble forming healthy
attachment to their children
Munchausen by Proxy
• This form of abuse claims the life of 9% of the
children that fall victim to it
• Extremely difficult to diagnosis which is why many
children die before doctors realize what is actually
happening
• Children often require extensive emergency
medical care and undergo several unnecessary
procedures or surgeries
Munchausen by Proxy
• Warning signs in a child
include:
o History of repeated injuries,
illnesses , hospitalizations or
surgeries
o Symptoms that don’t quite fit
any specific disease
o Symptoms that don’t match
test results
o Symptoms that improve under
medical care but get worse at
home
o Drugs or chemicals are found
in the child’s urine, blood or
stool
• Warning signs in the
caretaker include:
o Attention seeking behavior
o Striving to appear self
sacrificing and devoted
o Becoming overly involved with
doctors and medical staff
o Refusing to leave the child’s
side
o Exaggerating the child’s
symptoms
o Appearing to enjoy the hospital
environment and the attention
the child receives
Munchausen by Proxy
• Extremely difficult to diagnose
• Often goes undetected
• Increased awareness and education for physicians,
nurses and EMS
• “Virtually all of the caregivers have personality
disorders that lead them to behave in odd and
destructive ways, especially when they feel under
stress”
• Treatment is psychotherapy
Measles
• Leading cause of death in Children worldwide
• Discovered in the 9th century by a Persian physician
• In 1912 it became a notifiable public health disease
in the United States
• 1963 vaccine became available
• Prior to 1963 nearly all children got the measles by
age 15 and 3-4 million were infected every year.
• Prior to 1963: 400-500 people died, 48,000 were
hospitalized and 4,000 suffered encephalitis from
contracting measles
Measles
• 1978 the CDC set a goal to eliminate measles from
the U.S.
• The measles vaccine drastically reduced the
disease rate and by 1981 numbers were down by
80%
• 1989 due to measles outbreaks in schools the
American Academy of Pediatrics recommended a
second dose of the MMR vaccine for all children
• Measles was declared eliminated from the United
States in 2000.
Measles
• 2015: Large multi state outbreak linked to an
amusement park in California
• 2014: The U.S. experienced 23 measles outbreaks
including one of 383 cases occurring primarily
among the unvaccinated Amish community
• 2013: U.S. experienced 11 outbreaks with over 120
cases
• 2011: More than 30 countries worldwide reported
and increase in measles with France experiencing a
large outbreak. Most of the cases that were
brought to the Unites States came from France
Measles
• Caused by an infection with the rubeola virus
• Acute and highly contagious
• The virus lives in the mucus of the nose and throat of
an infected child or adult
• The infected person is contagious for 4 days before
the rash appears, and continues for about 4-5 days
afterwards
• Virus can live for up to 2 hours in the airspace where
the infected person coughed or sneezed
• So contagious that 90% of the people close to the
person who are not immune will become infected
Measles
Measles
Pertussis
• Highly contagious caused by the bacteria
Bordetella pertussis
• Bacteria attach to the cilia
• Bacteria releases toxins which damage cilia and
cause airways to swell
• Transmitted person to person by coughing or
sneezing
• Infected people are contagious for 2 weeks after
cough begins
Pertussis
• Known for uncontrollable violent coughing
• After fits of coughing when the person tries to take
a deep breath it may result in a whooping sound
• Can affect all ages but can be deadly in babies
less than one year.
• Disease starts with cold-like symptoms
• In babies the only symptom may be apnea
• Symptoms usually start 5-10 days after exposure
• Generally treated with antibiotics
Pertussis
Pertussis
Pertussis
• Worldwide estimated 48,500,000 million cases per
year with about 195,000 deaths
• 2012: there were 48,277 cases in the United States.
This was the largest number of cases in the U.S. since
1955.
Nicotine Poisoning
• E cigarettes utilize nicotine and flavoring dissolved in
a solution of propylene glycol, polyethylene glycol
and/or vegetable glycerin
• A small quantity of the liquid is passed over an
interior heating element producing a dense vapor
that simulates the smoke of burning tobacco
• Most E cigarettes have a self contained cartridge
with a refillable reservoir
• Reservoir holds 0.3 to 1.6ml of nicotine liquid
• The nicotine concentration ranges from 0-36 mg/ml
but can be as high as 72mg/ml
Nicotine Poisoning
• The liquid is called “e-liquid” or “smoke juice”
• It may be flavored to smell or taste like mint,
chocolate, coffee or various fruits
• Very concentrated
• Even a small taste can cause nicotine poisoning in
a child
• Middle school students are using e-Cigs at double
the rate from 2 years ago
• 10% of high school students smoke e-Cigs
Nicotine Poisoning
• In 2014 one half of reported exposures to liquid
nicotine occurred in young children under the age
of 6
• Year
Number of Cases
• 2011
271
• 2012
460
• 2013
1,543
• 2014
3,783
• 2015
3,073
• 2016
• Through May 31,2016 770
Nicotine Poisoning
• Number of children under 6 poisoned by nicotine
from e-cigarettes rose 1500% between 2013-2015
• More than 90% swallowed the nicotine laced liquid
• Children attracted by colorful bottles and flavors
Nicotine Poisoning
Nicotine Poisoning
•
•
•
•
•
Nicotine is highly toxic
Contents of liquid nicotine are unregulated
As little as 1 mg can cause symptoms in an infant
Nicotine acts on the brain
Mild nicotine poisoning causes
o
o
o
o
o
Nausea and vomiting
Dizziness
Tremors
Sweating
Elevated blood pressure
• Severe poisoning is life threatening and can lead to
seizures. Onset in as little as 20-30 minutes
Nicotine Poisoning
• Symptoms of Acute Nicotine Toxicity
o Gastrointestinal:
• Sharp burning in the mouth and throat on contact.
• Gagging, nausea, vomiting profuse salivation, abdominal pain and
cramping
o Central Nervous System
• Headache
• Dizziness
• Lethargy
• Agitation
• Confusion
• Delirium
• Seizures and coma
Nicotine Poisoning
• Cardiovascular
o Transient vasospasm-induced hypertension and tachycardia followed in
high doses by hypotension and bradycardia
o Arrhythmias and coronary ischemia
• Neuromuscular
o
o
o
o
Muscle fasciculation
Hypotonic muscles
Muscle weakness
Respiratory failure
• Nicotine Poisoning is known as nature’s muscle
relaxer
• Very few states require childproof packaging!
Nicotine Poisoning
• There is no specific antidote for nicotine
• Care is symptomatic and supportive
o
o
o
o
Fluids and vasopressors for hypotension
Atropine for bradycardia and excessive secretions
Benzodiazepines for seizures
Ventilator support for patients with muscle weakness or respiratory failure
•
• Half life of nicotine is an hour or less
• Mild toxicity rapidly resolves in 1 to 4 hours
• Severe toxicity may last18-24 hours
Detergent Pods
• New category of cleaning product
• In 2016, through June 30,poison centers received
reports of 6,429 exposures to highly concentrated
packets of laundry detergent by children 5 years
and younger.
• Children exposed to them experience
o
o
o
o
o
Excessive vomiting
Severe respiratory distress/ pulmonary edema
Burns to the esophagus
Burns to the eyes and skin
Coma
Detergent Pods
• Detergent Pods/packets emerged as the biggest
contributor to hospitalizations and serious medical
effects among any other kind of detergent
poisoning
• Detergent more highly concentrated
• Easier to digest
• The water-soluble membrane will dissolve quickly in
their mouth or pop when child bites it, which shoots
concentrated detergent down their throat and into
their airway
Detergent Pods
• Laundry detergent Pods have 3 main routes of
exposure: ingestion, ocular and dermal
• Ingestion most common route (80%)
• Polyvinyl membrane is easily soluble when exposed
to moist skin or saliva
• Ocular exposure can cause burning, irritation,
conjunctivitis and eye pain
• Dermal exposure results in rash and skin irritation due
to alkaline components.
Detergent Pods
• Treatments include;
o Stabilize airway, breathing and circulation
o Eyes should be irrigated early
o Contaminated clothing should be removed
• As a result of growing awareness many companies
in the Unites States have to committed to changing
packaging to make less appealing to children
Scenario
• You respond for the man “who is acting strangely
holding a bat.” Police are on scene and tell you
they were called for a naked man who was
swinging a bat and screaming at passing cars in the
middle of the street.
• Patient is a large obese man and he is screaming
“make them stop.”
• Officers are attempting to restrain him , utilizing
tasers several times and now have him handcuffed,
face down on the street. The patient is now quiet
and the police call you over to assume care.
Scenario
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•
•
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Your assessment reveals :
GCS score of 6 (E1 V1 M4)
Airway: Snoring respirations
Breathing: 8/ RR breath sounds diminished
Circulation: Bounding pulse, 160/min
Disability: Moves all extremities to pain
Pupils are dilated 8mm
Scenario
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•
•
•
•
•
S- Unconscious responds to painful stimuli
A- Unknown
M- Medications unknown
P- Past medical History unknown
L- Last meal unknown
E- Acting erratically and was tasered by police
several times. Taser barbs in place to back and
upper thighs.
Scenario
•
•
•
•
•
•
Vitals- B/P 260/130, Pulse 160 bounding RR 8
SpO2 92% Room Air
Blood glucose 130
Monitor: Sinus Tachycardia
Skin Flushed, very warm to touch, diaphoretic
Tympanic temp: 105.8
Scenario
• Treatment
• Oxygen?
• Patient starts to wake up and now becomes very
combative
• How do you handle this patient?
Excited Delirium
• Relatively uncommon health condition
• Characterized by severe agitation, distress,
aggression and sudden death
• Occurs most commonly in men
• First described in mid 1800’s also known as
o
o
o
o
Bell’s Catonia
Lethal catonia
Acute exhaustive mania
Agitated delirium
• Approximately 75% of individuals with this condition
died.
Excited Delirium
• The majority of cases since 1985 were associated
with stimulant drug reactions
• Cocaine appears to have the strongest link
• Most weren’t abusing but experiencing an
abnormal reaction to cocaine
• A metabolite of cocaine “benzoylecgonine” was
significantly higher in bloodstream
• Most cases of excited delirium are associated with
high mortality rate
• Has gained increasing public attention
Excited Delirium
• Methamphetamine is another culprit
• Also similar conditions occur with ingestion of LSD,
alcohol, Phencyclidine (PCP)
Excited Delirium
• Two most common causes of death for EMS include
o Cardiac arrest as a result of cardiac arrhythmia or tachycardia
o Respiratory failure due to inability to get sufficient levels of oxygen and
eliminate sufficient carbon dioxide
• Police restraint due to
o compression leading to decreased oxygen levels
o arrhythmias
o exacerbation of symptoms as a result of hyperventilation
o Positional asphyxia
o Taser usage resulting in disruption of heart rhythms
Treatment
• ABC’s
• Treatment will be subject to patient presentation
• Benzodiazepines: most commonly used. They slow
activity in the CNS and cause sedation
• Sodium Bicarbonate: If in cardiac arrest or shock
will mitigate severe acidosis patient may be
experiencing with consent of medical control
• Hyperthermia: reduce body temperature with cold
packs, water sprays or fanning, intravenous saline
• Monitoring
Status Epilepticus
• Status epilepticus refers to the occurrence of a
single seizure lasting longer than 5-10 minutes
refractory to intervention or frequent clustered
seizures without a return to baseline.
• Not associated with increased mortality but is linked
to prolonged hospitalization and poorer functional
outcomes
• Benzodiazepines remain the first-line treatment for
status epilepticus
Diastat
Drug of the Month
Rectal gel formulation of diazepam
Provides rapid delivery of the drug
Onset of action is 5-10 minutes
Using Diastat in the home situation controls the
seizure more quickly and often prevents the need to
call 911
• Comes in easy to use prepackaged, premeasured
doses
• Requires no refrigeration or special handling
• Has a 4 year shelf life
•
•
•
•
Diastat
• There are times when 911 should be activated.
• The healthcare provider that ordered the Diastat
sets parameters for calling 911with caregiver
• They would include
o
o
o
o
The seizure continues for 15 minutes after administering Diastat
Seizure behavior is different from usual episodes
Caregiver is alarmed by patient color or breathing
The person is having unusual or serious problems with seizure activity
• Adverse effects include: drowsiness, lethargy,
hypotension, agitation, confusion, dizziness, slurred
speech, headache, flushing, stomach pain and
diarrhea , CNS depression
Diastat
Diastat
ALS ONLY – Use of patient prescribed DIASTAT® (rectal Valium)
1. Trained paramedics may administer DIASTAT® (rectal Valium) to patients:
 The patient should be actively seizing for > 3 minutes, or having repeated
seizures without regaining consciousness, i.e. status epilepticus.
 The identity of the patient and the name on the prescription must match.
 The paramedic may assist and or administer DIASTAT® at the dose
prescribed.
 If any of these criteria are not met, follow regular PEDIATRIC SEIZURES /
STATUS EPILEPTICUS SOP, p. 94
2. Transport all patients who received this medication; if consent for transport is
refused by parent/guardian/power of attorney for health care, contact Medical
Control.
3. Call Medical Control for assistance with any refusals.
Scenario
• You respond to the home for a medical
emergency. On arrival you find a 6-year old female
with a complaint of sudden onset of “My heart is
running away.”
• She is alert and in no distress.
• Her mother denies that the child has any history of
heart disease and is in good health. This came on
very suddenly while watching TV.
Scenario
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•
Airway: Clear
Breathing: 22/ min unlabored
BP is 100/70 mm/Hg
Pulse oximetry is 95% on room air
You place her on the monitor and this is what you
see
Scenario
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•
•
•
•
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S: Feels like her heart is racing
A: None
M: None
P: no past medical history
L: Ate breakfast at 8am
E: watching TV when felt “her heart was running
away”
Scenario
• During transport you note that the child is less
responsive.
• Current vital signs are
o
o
o
o
Heart rate 230 BPM
Blood Pressure 80/50
Respirations 30
Pulse oximetry 93%
• Stable or Unstable?
• Treatment
o Oxygen
o Adenosine
o Cardioversion
Pediatric Tachycardia
• Tachycardia is common in the pediatric age group
• Often etiology is benign
• Requires rapid assessment of patient status and
cardiac rhythm
• Most life threatening cardiac conditions in children
that present as tachycardia consist of
supraventricular tachycardias
Supraventricular
Tachycardia
• Most common symptomatic dysrhythmia of
childhood
• May present with palpitations, chest pain or
shortness of breath in children with heart rates
• >180 BPM
• In infants symptoms are lethargy, feeding difficulties
or irritability with heart rates >220 BPM
• SVT most often caused by an accessory
atrioventricular pathway
Supraventricular
Tachycardia
Supraventricular
Tachycardia
• May be associated with :
o Drug exposure especially sympathomimetics contained in high caffeine
drinks
o Cough and cold medications
o Dietary supplements
o Congenital heart disease (especially Epstein anomaly)
• Not to be confused with ventricular tachycardia
which is uncommon in the pediatric population
Supraventricular
Tachycardia
Supraventricular
Tachycardia
• Vagal maneuvers may be utilized for children who
have mild or no symptoms while ECG is being
continuously monitored.
• Infants and younger children: an application of a
bag filled with ice and cold water over the face for
10-15 seconds
• Older children: bearing down (Valsalva maneuver)
for 10-20 seconds
Supraventricular
Tachycardia
• Adenosine is considered the drug of choice for
medical conversion
• Antiarrhythmic agent used to treat supraventricular
tachycardia that does not improve with vagal
maneuvers
• It slows the sinus rate and increases the AV node
conduction delay.
Pediatric Tachycardia
PEDIATRIC TACHYCARDIA
(> 180 BPM for age 1-15, > 220 BPM for < 1 year)
1. Pediatric Initial Medical Care SOP, p. 79
 Complete initial assessment. Assess for:
 Weak, thready or absent peripheral pulses
 Decreasing consciousness
 Tachypnea/Respiratory difficulty
 Central cyanosis and coolness
 Hypotension (late sign)
 Search for and treat potentially reversible causes:
 Hypovolemia
 Toxins (overdose)
 Hypoxia or ventilation problems
 Tamponade (pericardial)
 Hypoglycemia
 Tension pneumothorax
 Hypothermia
Stable
BLS / ALS
2. Contact Medical Control
3. Transport
 Support ABCs
 Keep warm
Narrow QRS (≤ 0.08 sec) – Possible SVT
Unstable
BLS
2. Contact Medical Control
3. Transport
 Support ABCs
 Keep warm
ALS
2. Establish VASCULAR ACCESS IV/IO
3. If probable SVT, give ADENOCARD (adenosine) 0.1 mg/kg rapid IV/IO push
(max dose 6 mg) ▲
5. If no conversion, repeat ADENOCARD (adenosine) at 0.2 mg/kg rapid IV/IO
push (max dose 12 mg) ▲
6. If ADENOCARD (adenosine) unsuccessful and patient remains unstable:
 Begin transport, and contact Medical Control
 SYNCHRONIZED CARDIOVERSION 1 J/kg while enroute
 If no response, may repeat SYNCHRONIZED CARDIOVERSION 2 J/kg
 Consider sedation with VERSED (midazolam) 0.1 mg/kg slow IV/IO or 0.2
mg/kg IN (maximum dose 6 mg < 5 years, 10 mg ≥ 5 years), but don’t
delay cardioversion