Download Pediatric emergency case conference

Pediatric emergency case
conference
Presented by R3 李智晃
General and triage information
Chart No. :7168xx9
Date of birth: 85/08/08
Gender: male
Body weight: 35kg
Time on arrival: 2006/06/19 PM 16:15
Vital signs: 36.3/200/20, BP not
measurable
 家屬主訴心悸，外院表示tachycardia，建議轉診
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Chief complaint and present illness
 C.C: palpitation since AM 10:00
 Present illness
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Chest tightness and SOB was noted
Activity: good
No vomiting
No cough, no fever
 Past history:
 Similar episode last year
Physical examination
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HEENT: no active lesion
Heart: tachycardia without murmur
Chest: clear breathing sound
Abdomen: sort and flat
Extremities: freely movable
Immediate EKG monitoring:
tachycardia up to 200/min
Was the patient ill?
 PAT
 Appearance- conscious clear, good
activity
 Breathing- mild tachypnea
 Circulation- tachycardia, BP not
measurable, strong peripheral pulsation,
no cold or mottled skin
EKG on arrival
Initial management
 Adenosine 3.5 mg IV stat
 On 3-way lock
 CBC/DC, CK-MB, Troponin-I, Ca, Na,
K,BUN
 Admission to ward
 On EKG monitor
ECG after treatment
Final diagnosis
 Paroxysmal supraventricular
tachycardia
 WPW syndrome
PSVT - Pathophysiology
Introduction and epidemiology
 Prevalence around 1/250-1/25000
 Most common form
 AVRT (including WPW syndrome)
 AVNRT
AV reentrant tachycardia (including
WPW syndrome)
 presence of an extranodal accessory
pathway connecting the atrium and
ventricle
 Antegrade vs. retrograde
 Antidromic vs. orthodromic
Antegrade versus retrograde
Pre-excitation caused by antegrade conduction by accessory pathway.
So-called Wolff-Parkinson-White (WPW) pattern.
Orthodromic tachycardia WPW
Antidromic tachycardia WPW
12 lead ECG in antidromic AVRT
WPW
PSVT - management
PALS algorithm for SVT
Hemodynamic assessment - PAT
 Appearance- pallor, or decreased level
of consciousness
 Breathing- tachypnea, subcostal
retraction, use of accessory muscle
 Circulation- hypotension, heart failure,
signs of shock,.
 Signs in infants- irritability, tachypnea,
and poor feeding.
Hemodynamic unstable
 Cardioversion
 Direct current cardioversion at 0.5 to 2.0
J/kg, synchronized
 Use pediatric electrode paddles (surface
area 21 cm2)
 Adequate sedation before the procedure
Diagnostic evaluation
 History incompatible with sinus
tachycardia
 P waves absent or abnormal
 Heart rate does not vary with activity
 The presence of abrupt changes in
heart rate
 Rate usually >220 beats/min in
infants and >180 beats/min in
children
Vagal maneuvers
 ECG should be continuously monitored
 Infant and younger children
 Application of a bag filled with ice and cold water
over the face for 15 to 30 seconds
 Rectal stimulation using a thermometer
 Older children
 bearing down (Valsalva maneuver) for 15 to 20
seconds
 Carotid massage and orbital pressure
should not be performed in children
Antiarrhythmic drugs
 Used while failure to convert the
rhythm with vagal maneuvers
 Drugs of choice
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Adenosine
Verapamil
Procainamide
Amiodarone
Digoxin was not suggested, especially
under the suspicion of WPW syndrome
Adenosine
 Mechanism
 Interact with A1 receptor of cardiac muscle
 Delay of AV nodal conduction
 Block the re-entry cycle
 Dosage
 0.1mg/kg, doubled if no response in 2 minutes
 0.05mg/kg, increase by 0.05mg/kg every 2
minutes to total maximal dose of 0.25 to
0.35mg/kg or total 12mg is given
Verapamil
 Mechanism
 to slow AV nodal conduction
 Dosage
 intravenous infusion in a dose of 0.1 to 0.3
mg/kg with a maximum dose of 10 mg
 Contraindications
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Infant less than one year old
Children with heart failure
Children suspected with WPW syndrome
Children with wide QRS complex
Procainamide
 No IV form in CGMH
 Mechanism
 inhibiting phase 0 (sodium-dependent)
depolarization and slows atrial conduction
 Dosage
 Loading dose
 Infant- 7 to 10 mg/kg is given over 30 to 45
minutes
 Oldr children- 15 mg/kg
 continuous infusion of procainamide starting at
40 to 50 mcg/kg per minute
Amiodarone
 Used for SVT refractory to other anti-arrhythmic
agents
 Can be used safely in patient with WPW syndrome
 Mechanism
 prolongs the refractory period of the AV node and the
duration of the action potential and the refractory
period of both atrial and ventricular myocardium
 Dosage
 bolus infusion of 5 mg/kg over 20 to 60 minutes,
repeated up to a total of 20 mg/kg
 Continuous infusion of 10 to 15 mg/kg per day.
Chronic therapy
 ECG after acute episode should be
performed to look for evidence of
WPW syndrome
 Medications
 Digoxin
 Radiofrequency ablation
Reference
 Up to date. Ver. 14.2
 Supraventricular tachycardia in children:
AV reentrant tachycardia (including WPW)
and AV nodal reentrant tachycardia
 Management of supraventricular
tachycardia in children
 Pediatric advanced life support (PALS),
2nd edition