PALS: Tachycardia

1) Evaluate Patient

[definition]

Info: normal HR and definition of tachycardia vary with patient age

[assess respiratory and cardiac status]

Info: confirm pulse present; maintain patent airway, assist breathing as needed; give oxygen if hypoxemic; pulse oximetry; monitor BP; cardiac monitor to assess rhythm; establish IV/IO access; 12-lead ECG if available; do not delay cardioversion if patient unstable

2) Evaluate QRS Duration

[QRS 0.09sec or less]

Info: narrow QRS; probable sinus tachycardia or SVT

[QRS >0.09sec]

Info: wide QRS; possible VT

3) Narrow QRS: Probable Sinus Tachycardia

[findings]

Info: QRS 0.09sec or less; P waves present or normal; variable RR; constant PR; HR regular, usually <220/min (infant) or <180/min (child); compatible history consistent with known cause

[monitor and observe]

Info: identify and treat reversible causes

4) Narrow QRS: Probable SVT

[findings]

Info: QRS 0.09sec or less; P waves absent or abnormal; RR not variable, usually 220/min or greater (infant) or 180/min or greater (child); history of abrupt rate change

[consider vagal maneuvers]

Info: Valsalva maneuvers for older child; apply ice to face without occluding airway for infant or young child; do not delay chemical or electrical cardioversion if unstable

[adenosine if regular narrow complex]

Dose: 0.1 mg/kg/dose IV/IO x1, then 0.2 mg/kg/dose IV/IO x1 prn after 1-2min; Max: 6 mg initial dose, 12 mg subsequent dose; Info: give all doses rapid IV push over 1-3sec, follow each dose with 5 mL or greater NS flush; decr. initial dose only if cardiac transplant patient or central line; contraindicated in patients with asthma

[consider synchronized cardioversion]

Dose: 0.5-1 J/kg x1, if ineffective incr. to 2 J/kg x1; Info: consider if no IV/IO access, adenosine ineffective, or patient unstable; sedate prior to cardioversion if possible without delay

[consider antiarrhythmic therapy]

Info: reserve for patients with SVT and cardiopulmonary compromise unresponsive to vagal maneuvers and adenosine and/or cardioversion; obtain expert consultation; use single antiarrhythmic agent

amiodarone 5 mg/kg/dose IV/IO x1 over 20-60min, then 5 mg/kg/dose IV/IO x2 prn up to 15 mg/kg total dose; Max: 300 mg/dose

procainamide 15 mg/kg/dose IV/IO x1 over 30-60min

sotalol 1 mg/kg/dose IV x1

5) Wide QRS: Possible VT

[findings]

Info: QRS >0.09sec; rhythm regular (VT or SVT with aberrancy), irregular (afib with aberrancy or pre-excited afib), or polymorphic (torsades de pointes)

[synchronized cardioversion if unstable]

Dose: 0.5-1 J/kg x1, if ineffective incr. to 2 J/kg x1; Info: sedate prior to procedure if possible without delay

[consider adenosine if rhythm regular and monomorphic]

Dose: 0.1 mg/kg/dose IV/IO x1, then 0.2 mg/kg/dose IV/IO x1 prn after 1-2min; Max: 6 mg initial dose, 12 mg subsequent dose; Info: may help differentiate SVT from VT; do not use if known WPW syndrome and wide-complex tachycardia; give all doses rapid IV push over 1-3sec, follow each dose with 5 mL or greater NS flush; decr. initial dose only if cardiac transplant patient or central line; contraindicated in patients with asthma

[expert consultation is advised before additional drug therapies]

6) Treat Reversible Causes

[6H's]

hypovolemia, hypoxia, hydrogen ion (acidosis), hypoglycemia, hypo/hyperkalemia, hypothermia

[5T's]

tension pneumothorax, tamponade (cardiac), toxins, thrombosis (pulmonary), thrombosis (coronary)