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Anthony F. Rossi, MD Director, Cardiac Critical Care Services Miami Childrens Hospital Miami, Fl
ECG Basics
Atrial Depolarization
Ventricular Depolarization
NSR
Arrhythmia Categories
Tachycardias
SVT Junctional Ventricular
Bradycardia
SND HB
Asystolic
Mechanisms of Tachyarrythmias
Reentry Abnormal automaticity After deploarizations
Reentrant Arrhythmias
Paroxysmal
Acute start Acute termination No warm up
Reentrant Loop
Abnormal Automaticity
warms up / cools downs not initiated by extrastimulus not terminated by extra stimulus no overdrive suppression
Abnormal Automaticity
1 2 0 3 4 0
threshold potential
-40
0 0 3 4 -40 -60
TP1 TP2 a
b
resting potential
SVT
Most common treated arrhythmia in children Almost never life-threatening in otherwise well children Infancy common presentation age May resolve as child matures
SVT: Presentation
Infants
Poor feeding Pallor S+S of CHF
Older Children
Palpitations Chest pain/discomfort
Orthodromic SVT
ECG Dx of SVT
AV recip tach AVN reentry PJRT -Short prlong rp
-fast-slow
r p
p r
SVT: Treatment
Adenosine
50-500 mcg/kg Rapid IV pushWide Complex Tachycardia after Adenosine Malignant MayAdministration to a Pediatric Postoperative Patient with transiently convert to NSR Congenital Heart Disease Transient SND, Pediatr Cardiol. 1995 Jan-Feb;16(1):36-7. Kipel et al. PVCs Systemic Vasodilatation most dangerous side effect
SVT: Treatment
Synchronized Cardioversion Begin antiarrhythmic agents, then attempt adenosine/cardioversion at later date Drugs:
Digoxin (IV in sick babies) Procainamide Verapamil (contraindicated in pts < 1 yr) B-blocker
WPW
Delta wave
Short pr
WPW
WPW
Ebsteins (9%), L-TGA (1%), HCM (1%) Narrow complex tachycardia most common Digoxin is contraindicated (accelerated ventricular response) B-blocker or amiodarone
PAC
Antidromic SVT
Afib WPW
NSR?
18 yo s/p Mustard operation presents feeling tired Adenosine 6 mg iv push given
Diagnosis is atrial flutter (intra-atrial reentry) -treatment options include -cardioversion -overdrive pacing (TEP or transvenous) -medical cardioversion (class lll agent ibutilide)
SVT ?
NB infant with HR of 240 BPM
Atrial Flutter
Atrial Flutter
Most frequently seen in infants or older pts after atrial surgery (Mustard/Senning, Fontan) Treatment depends on duration and degree of hemodynamic compromise Is there evidence of SND?
Atrial Flutter
Conversion
Cardioversion Pharmacologic (acute, sub-acute, chronic)
Atrial Flutter
SND
Need the ability to pace since SNRT may be very prolonged after cardioversion (overdrive suppression of SN) Epicardial wires Transvenous wires TE wire
Atrial Flutter
Death
Prolonged pause after conversion Rapid ventricular response in pt with structural heart disease Anesthesia induction (loss of sympathetic tone leads to hypotension and coronary perfusion problem)
Atrial Fibrillation
PJRT
P
8 yo girl transferred to the ER with Dx of DCM, severe LV dysfunction
PJRT
Atypical or fast-slow type SVT Incessant nature May cause tachycardia induced cardiomyopathy Resistant to drug therapy Terminates with adenosine, but only transiently
PVC
QRS is premature Morphology of QRS is different from baseline (did you see the po ECG?) QRS is prolonged ST abnormalities No PAC noted
Bigeminy
V Tach
V Tach
V Tach
V Tach: Treatment
Clinical condition Underlying disease state
V Tach: Treatment
-Procainamide converted 80% V tach
V Tach: Long QT
Congenital
Intense emotions, vigorous activity, awakening Auto Dom: RomanoWard Auto Rec: Jervell and Lange-Nielsen B-blocker, pacing, AICD
Acquired
Pause dependent, short-long-short QRS sequence Antiarrhythmics, phenothiazines and tricyclics, low K, low Mg DC causative agent, IV Mg, K, temp pacing, isoprel
V Tach: Treatment
Hemodynamically unstable
Cardioversion!!!
Torsade de Pointes
Long Qt
V Tach: Long QT
Congenital
Occur in > 25% of patients (CHOP) <10% MCH (JET 0.9%, CHB requiring pacemaker 0.15%) Risk Factors At Risk myocardium (long standing hypertrophy, volume load, etc.) Myocardial ischemia, cardioplegia Ventriculotomy Electrolyte Disturbances Majority of clinically significant arrhythmias occur with first 48 hours of surgery Marino BS, et al Circulation 2000
Hoffman TM, et al Ped Cardiol 2002 Fishberger SB, et al Cardiol Young 2007
IV Amiodarone
repeat in 1 hour if arrhythmia control is not satisfactory AV pace if ventricular rate allows add procainamide if poor response o cool to 35 C
CHB
Congenital
1/20,000 births
Acquired
Post surgery
Usually related to VSD closure
Bradycardias
SND Second degree heart block
Mobitz 1 Mobitz 2
Sinus Bradycardia
Most common bradyarrhythmia in the ICU Usually related to hypoxia and airway problems
Treat underlying cause Atropine Epinephrine Isuprel
SND
Most commonly seen in pts with a previous history of Mustard/Senning Operation Fontan operation BiGlenn Occasionally noted acutely following surgery Often associated with atrial arrhythmias (flutter:tachy-brady syndrome) Important historically because drug therapy may exacerbate Pauses of > 3 sec often noted after termination of tachycardia
Mobitz 1 (Wenckebach)
Increasing PR interval leading to block Shortest PR after blocked beat Block occurs in AV node (above HIS) May be related to drugs which block the AV node, or increased vagal tone Usually benign Rarely requires treatment Occurs in pts with normal conduction system
Mobitz II
CHB
CHB
Treatment
Depends on symptoms Acute treatment includes
Atropine Epinephrine Isuprel Pacing
Post surgical CHB requires permanent pacing Transient HB in PO period may progress to CHB later in life
Trifascicular Block
1. Ist degree AVB PR=0.22 2. RBBB 3. LAHB
Electrical Alternans