Transcript Pediatric Arrhythmias PPT

PEDIATRIC ARRHYTHMIAS
TORY WEATHERFORD, PGY - 3
 NO DISCLOSURES
NORMAL HEART RATE RANGES
INTERVALS
 PR INTERVAL LENGTHENS FROM INFANTS TO
CHILDREN
 QRS INTERVAL LENGTHENS
T-WAVES
 REMINDER: T WAVES FLAT OR INVERTED IN
NEWBORNS
 T WAVE INVERSION IN RIGHT PRECORDIAL LEADS
INTO CHILDHOOD/EARLY ADOLESCENTS
Non – Pathologic Arrhythmia
 Sinus arrhythmia
 P-P interval variation
 Exaggerated with respirations
 Maybe more pronounced in infants
Other benign arrhythmias





Isolated premature ventricular beats (upto 40%)
Isolated supraventricular beats
First degree A-V block
Mobitz I sedond degree block
Junctional arrhythmias
 Arrhythmias tend to be well tolerated
 Signs and symptoms – palpitations, fatigue, syncope
Neonates – poor feeding, irritablity
 IN KIDS WITH STRUCTURALLY NORMAL HEARTS –
MECHANISMS OF ARRYTHMIAS TEND TO BE SIMILAR
TO ADULTS
 MORE COMMON TO SEE – ACCESSROY PATHWAYS,
ATRIAL FOCI, DUAL AV NODAL PHYSIOLOGY
 IN STRUCTURAL ABNORMAL HEARTS – ARRTHYMIA
2/2 UNDERLYING ABNORMALITY, SURGICAL
INTERVENTION, HEMODYNAMIC STRESS
Tachycardias
Supraventricular Tachycardia
 Upto 13% of pediatric arrhythmias
 Incidence of 0.1 – 0.4%
 2 types – AV node re-entrant Tachycardia, accessory
pathway – AV reentry tachycardia
AVRT
 ATRIOVENTRICULAR REENTRY TACHYCARDIA
 MUSCULAR PATHWAY
 ACCESSORY PATHWAY/ORTHODROMIC
TACHYCARDIA
 MOST COMMON TYPE OF SVT IN KIDS – 82%
ARRHYTHMIAS IN INFANCY
AVNRT
 RE-ENTRANT CIRCUIT THAT INVOLVES AV NODE
 2 CONDUCTION LIMBS – FAST AND SLOW
 ~15% OF SVT IN PEDIATRICS
SVT
 BOTH WELL TOLERATED
 OFTEN INDISTIGUISHABLE
CLINICAL FEATURES
 ASYMPTOMATIC
 INFANTS – POOR FEEDING, IRRITABLITY, PALLOR
 KIDS/TEENS – CHEST PAIN, DIZZINESS, SYNCOPE,
PALPITATIONS, SOB
 S/SX OF HEART FAILURE IN INFANTS IF
UNRECOGNIZED
EKG FINDINGS





HR >220 IN INFANTS, >180 KIDS
NARROW QRS
AV RATIO 1:1
AVRNT – ? TERMINAL QRS NOTCHING
AVRT - ? INVERTED P WAVES
WPW
 Short P-R interval
 Widened QRS
 Delta Wave
ACUTE MANAGEMENT




VAGAL MANUEVERS
ADENOSINE
CARDIOVERSION
ABLATION
FURTHER WORKUP
 REPEAT EKG ONCE IN NSR
 LABWORK – ELECTROLYTES, TSH, CBC
 ADMISSION IF LESS THAN ONE, AND
HEMODYNAMICALLY UNSTABLE
 FIRST TIME EPISODE – OBSERVATION OVERNIGHT
 CARDIOLOGY CONSULT – MANAGEMENT OF MEDS
 CARDIOLOGY FOLLOW UP IF PRE-EXCITATION ON
EKG AND ASYPTOMATIC
ATRIAL TACHYCARDIAS
 USUALLY IN NEWBORN PERIOD, UNLESS S/P
CARDIAC SURGERY
 COMMON S/P FONTAN, ASD REPAIR, AND
TETRALOGY REPAIR
 SINGLE REENTRY CIRCUIT
 HD INSTABILITY CORRELATES WITH DEGREE OF
BLOCK – 1:1 WORST
CLINICAL FEATURES
 OFTEN DIAGNOSED IN-UTERO
 FETAL HYDROPS IF PROLONGED
 MOST NEWBORNS ASYMPTOMATIC IF TACHY< 48
HOURS
 INFANTS – POOR FEEDING, LETHARGY, PALLOR,
DIAPHORESIS
 OLDER KIDS – CHEST PAIN, PALPITATIONS, DIZZINESS
Acute Management
 Vagal maneuvers and adenosine may slow conduction
revealing p-waves w/o termination
 If Unstable – Cardioversion 0.5j/kg upto 1-2J/kg
 If stable – Rate control with Bblockers, CCBs, rhythm
control with amiodarone or ibutilide
Further workup
 Labs – CBC, lytes, thyroid function
 Cardiology consult & Echo to rule out structural
disease, thrombus formation
 Admit for obs
 Anticoagulation if >48 hour or s/p Fontan
ECTOPIC ATRIAL TACHYCARDIA




~10% SVT IN CHILDREN
MCC OF TACHYCARDIA INDUCED CARDIOMYOPATHY
ETIOLOGY – VIRAL VS. TUMOR VS. GENETICS
VARIABLE PRESENTATION – FAIRLY BENIGN TO
HEART FAILURE
ACUTE MANAGEMENT
 Responds poorly to adenosine and cardioversion
 1st line – Amiodarone bolus 5mg/kg over 20-60
minutes
 Maintenance drip 10-15 mg/kg/day
 If asymptomatic – no treatment
FURTHER WORKUP
 Labs – cbc, lytes, tsh
 Cardiology consult – echo, 24 hour monitor
 Treatment depends on age, cause, symptomatology,
clinical status
 If less than 1 year or symptomatic – admission for
arrhythmia management and cardiac failure
ATRIAL FIBRILLATION
 MOST COMMON IN STRUCTURALLY ABNORMAL
HEARTS, PRIOR CARDIAC SURGERY
 STRUCTURALLY NORMAL HEARTS - ASSOCIATION
WITH ACCESSORY PATHWAY CONDUCTION AND
SUDDEN DEATH
 SEEN IN MYOCARDITIS, PERICARDITIS,
HYPERTHYROID, GENETIC CAUSES
ACUTE MANAGEMENT
 UNSTABLE – CARDIOVERSION 2J/KG
 STABLE – RATE VS RHYTHM CONTROL –
AMIODARONE/IBUTILIDE.
FURTHER MANAGEMENT
 LABS – CBC, CHEMISTRY, THYROID, TOX
 FURTHER TESTING IF CARDIOMYOPATHY IS
CONSIDERED – BCS, VIRAL PANEL, ENZYMES
 ECHOCARDIOGRAM
 ADMISSION FOR OBS/TREATMENT
 ANTICOAGULATION IN MOST CASES
WIDE COMPLEX TACHYCARDIAS
 DDX:
 V-TACH
 SVT WITH BUNDLE BRANCH BLOCK
 SVT WITH PRE-EXCITATION IN WPW
 TREATMENT – ALL AS VTACH, PRIOR EKGS CAN BE
HELPFUL
V-TACH
 RARE - ~6% OF TACHYCARDIAS
 SUSTAINED VS NON-SUSTAINED
 MONOMORPHIC, REGULAR RATE, SINGLE QRS
MORPHOLOGY
 ETIOLOGIES: Idiopathic, drug toxicity,
cardiomyopathy, myocarditis, cardiac tumors and
metabolic abnormalities
ACUTE MANAGEMENT
 IF UNSTABLE – CARDIOVERSION AT 2J/kg then
increasing
 IF STABLE - Amiodarone at 5mg/kg IV over 30–60
minutes or procainimide at 15mg/kg IV over 30–60
minutes
FURTHER WORKUP
 Very thorough history – cardiomyopathy, toxins, family hx
of sudden cardiac death
 Ekg to r/o – Brugada syndrome, long Q-T, arrhythmogenic
right ventricular cardiomyopathy, electrolyte
abnormalities, structural heart disease, ischemia
 Cardiology consult
 Echo
 Admission for observation
 ?Amiodarone gtt
CONGENITAL LONG Q-T
 MAY CAUSE SUDDEN CARDIAC DEATH
 ABNORMALITIES IN ION CHANNELS --- TORSADES,
OFTEN PRECIPITATED BY ADRENERGIC STIMULI
 ACQUIRED LONG QT 2/2 – DRUGS, ELECTROLYTE
ABNORMALITIES, UNDERLYING MEDICAL CONDITION
PRESENTATION
 PRE-SYNCOPE, SYNCOPE, SEIZURES, OR CARDIAC
ARREST
 RARELY – INFANTS – POOR FEEDING, LETHARGY,
CYANOSIS, POOR PERFURSION
 PRECIPATING FACTORS – EXERCISE, SWIMMING,
EMOTIONAL STRESS, LOUD NOISES
 EKG FINDINGS: Sinus rhythm ECG, QTc of >460 in
post-pubertal females and 450 in others, best
obtained from lead II (Bazett Formula QTc= QT
Interval/√-RR).
 IF >440 AND correct clinical symptoms – further
investigation
ACUTE MANAGEMENT
 FOR TORSADES – DEFIBRILLATION, MAGNESIUM
 CORRECT UNDERLYING PROBLEM IF ACQUIRED
 IV BETA BLOCKERS MAY CALM ADRENERGIC STORM
FURTHER MANAGEMENT
 THOROUGH HISTORY AND FAMILY HX, ESP HISTORY
OF INCITING EVENT
 MEDICATION REVIEW
 LABS – LOOKING FOR ELECTROLYTE ABNORMALITY
 IF IN VTACH – ADMIT FOR OBS, ECHO, CARDIOLOGY
CONSULT
 INCIDENTAL FINDING – OUTPATIENT CARDIOLOGY
FOLLOW UP
 SCREEN FAMILY MEMBERS WITH EKG
OTHER CHANNELOPATHIES
 SHORT Q-T SYNDROME – SYNCOPE, HIGH RISK OF
SUDDEN CARDIA DEATH
 BRUGADA SYNDROME
 IDIOPATHIC V FIB
 SICK SINUS SYNDROME
 LEV-LENEGRE SYNDOME – PROGRESSIVE CARDIAC
CONDUTION DISEASE
CONGENITAL HEART DISEASE
 DESPITE REPAIR – LIFETIME INCREASE IN
ARRYTHMIAS
CHD & ASSOCIATED ARRHYTHMIA
TETRALOGY OF FALLOT
DOUBLE OUTLET RV
ATRIAL TACHYCARDIA
V TACH
SINUS NODE DYSFUNCTION
TRANSPOSITION OF VESSELS
VENTRICULAR ARRHYTHMIA
AV BLOCK
EBSTEINS ANOMALY
SVT
VSD
ATRIAL SEPTAL DEFECT
HEART BLOCK
VENTRICULAR ARRHYTHMIA
ATRIAL TACHYCARDIA
ASD REPAIR
SINUS NODE DYSFUNCTION
CARDIOMYOPATHIES
 HYPERTROPHIC CARDIOMYOPATHY
 DILATED CARDIOMYOPATHY
 ARRYTHMOGENIC RIGHT VENTRICULAR DYSPLASIA
 VTACH AND SUDDEN DEATH
 EKG – RIGHT VENTRICULAR CONDUCTION DELAY,
INVERTED T WAVES, AND PVCS
 PRESENTS WITH SYNCOPE DURING EXERCISE
INDICATIONS FOR ICD
 CLASS I –
 SECONDARY PROPHYLAXIS AFTER CARDIAC ARREST
WHERE NO REVERSIBLE CAUSE WAS FOUND IN A
NORMAL HEART, CHD, CARDIOMYOPATHIES OR
CHANNELOPATHIES
 SYMPTOMATIC SUSTAINED VT IN PATIENTS WITH CHD
 SYMPTOMATIC SUSTAINED VT IN PATIENTS WITH
CARDIOMYOPATHIES AND SIGNIFICANT LV
DYSFUNCTION
ICDS
 CLASS II INDICATIONS:
 CHD WITH RECURRENT SYNCOPE AND VENTRICULAR
DYSFUNCTION OR INDUCIBLE VENTRICULAR
ARRHYTHMIAS
 LONG QT SYNDROME AND MEDICATION NON
COMPLIANCE, OR FAMILY HX OF SUDDEN DEATH
 HCM WITH 1 OR MORE RISK FX – HX OF SUDDEN
DEATH, NON RESPONSIVE TO MEDS
REFERENCES
 TINTINALLI’S EMERGENCY MEDICINE
 CROSSON, HENASH “EMERGENCY DIAGNOSIS AND
MANAGEMENT OF PEDIATRIC ARRHYTHMIAS”
JOURNAL EMERGENCY TRAUMA AND SHOCK 2010
SEPTEMBER 251-260.
 Uptodate “Irregular Heart Beats in Children”
 http://lifeinthefastlane.com/ecg-library/paediatric-ecginterpretation/
REFERENCES
 EHRA/AEPC CONSENSUS STATEMENT
“Pharmacological and non-pharmacological therapy
for arrhythmias in the pediatric population: EHRA and
AEPC-Arrhythmia Working Group joint consensus
statement” JULY 12, 2013
 http://www.pedicardiology.net/search/label/EKG