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1) Confirm Diagnosis:
a. Heart rate >170 bpm.
b. AV dissociation
c. Ventricular rate > Atrial rate
2) Confirm that JET needs treatment…if the patient is “hemodynamically stable”
with JET, just observe. (You can worsen hemodynamics by trying to treat JET
which did not need treatment).
3) Control fever, institute hypothermia (~35-36° C)…Treatment of fever, turn
down humidifier temperature on the ventilator to 35° C and cooling blanket…
in that order. If actively cooling, adequate sedation and muscle relaxants will
be needed to prevent shivering – especially if temperatures < 35° C are
aimed.
4) Reduce circulating catecholamines:
a. Reduce Dopamine dose…perhaps other catecholamines that are being
infused.
b. Adequate pain control, sedation and muscle relaxation as needed.
5) Medications:
a. Amiodarone
i. Bolus doses: 2.5 mg/kg/dose over 10 minutes, Wait for 20-30
minutes (max. 60 min) to determine response.
ii.Repeat to a maximum of 10 mg/kg
iii.Consult EP of further loading (to a max of 15 mg/kg) is felt
necessary.
b. Amiodarone infusion
i. Determine that the infusion is necessary. If needed, use a range
of 3.5 mcg/kg/min – 7 mcg/kg/min (≈ 5mg/kg/day – 10
mg/kg/day).
ii.Consult EP service if doses higher than 7 mcg/kg/min is felt
necessary.
6) Use fluid boluses/Calcium infusions if needed to treat hypotension caused by
Amiodarone – if appropriate for the baby’s condition.
7) Atrial Pacing:
a. If the junctional rate comes down below 150 or 140, you may A-pace at
a rate 10-20/min above the junctional rate. When you set the
pacemaker, watch and document that atrium is captured, AV
conduction exists and QRS complex follows.
b. Also, document the response to pacing…there should be some
improvement in hemodynamics with addition of AV synchrony. Use this
improvement to reduce any other catecholamine infusions.
c. If there is no AV conduction (either not present or can’t be
ascertained), set the pacemaker for DDD pacing…remember to check
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on AV interval and PVARP settings (If you don’t know what these are,
please get someone who knows. Don’t guess!).
8) Second-line medications are not usually needed. Consult EP service regarding
Procainamide or other medications.
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Annotated Bibliography:
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