5. PEDIATRIC EMERGENCIES
5.9 PEDIATRIC SUPRAVENTRICULAR TACHYCARDIA (SVT)
Supraventricular Tachycardia is the most common dysrhythmia producing cardiovascular instability during infancy, and it can occur throughout the pediatric years. However, it is critical that the rhythm be differentiated from sinus tachycardia, which is seen more often: some common causes of sinus tachycardia are dehydration, shock, hyperthermia, anxiety, pain and fear. Treatment should be directed towards the underlying causes. Supraventricular Tachycardia in infants often produces a heart rate of 240 beats per minute and possibly up to 300 beats per minute. Wide QRS Pediatric Supraventricular Tachycardia is relatively uncommon in infants and children. Any wide-QRS tachycardia should be assumed to be of ventricular origin. Heart rates up to 220 can be due to sinus tachycardia in children. Supraventricular Tachycardia in pediatric patients usually results from an abnormality of the cardiac conduction system. Although the heart rate can vary, it rarely needs treatment if under 220 in children.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated.
3. Administer high concentration of oxygen via non-rebreather mask.
4. Determine patient's hemodynamic stability and symptoms. Continually assess level of Consciousness, ABCs and Vital Signs including capillary refill and determine if appropriate for age.
5. Obtain appropriate history related to event, including Past Medical History (prior episodes of Supraventricular Tachycardia or underlying congenital heart disease and/or surgery), Medications, Drug Allergies and Substance Abuse including possible ingestion or overdose of medications. Determine if there is a history of possible causes for sinus tachycardia, such as fluid loss, fever, shock, or bleeding.
6. Symptomatic patients will have heart rates greater than 220 bpm, and one of the following signs of hypoperfusion: decreased level of consciousness, weak and thready pulses, delayed capillary refill, or no palpable BLOOD PRESSURE.
TREATMENT
BASIC PROCEDURES
Note: Inasmuch as Basic EMTs are unable to recognize the presence of PSVT, check the patient for a rapid or thready pulse and manage according to the following protocol:
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated.
3. Administer oxygen by nasal cannula or by non-rebreather mask.
4. If tachycardia is related to acute injury or volume loss, see Pediatric Shock Protocol.
5. Activate ALS intercept, if deemed necessary and if available.
6. Initiate transport as soon as possible with or without ALS.
7. Continue to monitor vitals signs.
8. Notify receiving hospital.
INTERMEDIATE PROCEDURES
Note: Inasmuch as Intermediate EMTs are unable to recognize the presence of PSVT, check the patient for a rapid or thready pulse and manage according to the following protocol:
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated.
3. Administer oxygen by nasal cannula or by non-rebreather mask.
4. If tachycardia is related to acute injury or volume loss, see Pediatric Shock Protocol.
5. Activate Paramedic intercept, if deemed necessary and if available.
6. ALS STANDING ORDERS
a. Advanced Airway Management if indicated.
b. IV Normal Saline (KVO), while en-route to hospital, if vein is visible and/or palpable.
7. Initiate transport to appropriate medical facility as soon as possible with or without Paramedics.
8. Continue to monitor vitals signs.
9. Notify receiving hospital and Contact MEDICAL CONTROL. The following may be ordered:
a. Fluid bolus of Normal Saline (expected fluid bolus of 20 ml/kg).
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated.
3. Administer oxygen by nasal cannula or by non-rebreather mask.
4. If tachycardia is related to acute injury or volume loss, see Pediatric Shock Protocol.
5. ALS STANDING ORDERS
a. Advanced Airway Management if indicated.
b. IV Normal Saline (KVO). If hypovolemic component is suspected, administer 20 ml/kg IV Bolus of Normal Saline.
6. Continue to monitor vital signs.
7. Initiate transport to appropriate medical facility as soon as possible.
8. Contact MEDICAL CONTROL. The following may be ordered:
a. Additional fluid boluses of Normal Saline (20 ml/kg).
b. Synchronized cardioversion 0.5 joules/kg for symptomatic patients.* Subsequent cardioversions may be given up to 1.0 joules/kg. If cardioversion is warranted, consider administration of any of the following for sedation:
- Valium: if patient < 70 kg: 2.5 mg SLOW IV Push or
- Versed 0.5 mg - 2.5 mg SLOW IV push or
- Morphine Sulphate 2.0 mg - 5.0 mg IV or IM.
c. Adenosine 0.1 mg/kg IV Rapid IV push. If no effect, repeat Adenosine 0.2 mg/kg Rapid IV push. MAXIMUM single dose of Adenosine must not exceed 12 mg.
d. Vagal maneuvers (see second Reminder below).
9. Notify receiving hospital.
*Synchronized cardioversion should be considered for only those children whose heart rate is in excess of 220, and who demonstrate one or more of the following signs of hypoperfusion: Decreased level of consciousness, weak and thready pulses, capillary refill time of more than 4 seconds, or no palpable BLOOD PRESSURE.
REMINDER: Verapamil HCL should not be used in infants because cardiac arrest has been reported following it's administration, and its use is discouraged in children as it may cause hypotension and myocardial depression. No data is available to support the safe Pre-hospital use of Verapamil in children.
REMINDER: Vagal maneuvers may precipitate asystole and therefore should be employed with caution in the field and only in a cardiac-monitored child with IV access.
MoonDragon's EMS Index Page
HELPFUL PRODUCTS & FURTHER EDUCATION
-- by Phyllis A. Balch, James F. Balch - 2nd Edition
-- by Phyllis A. Balch, James F. Balch - 4th Edition
-- by Phyllis A. Balch
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