PALS Provider: Course
Pediatric Tachycardia Algorithm
Tachycardia in children can result from normal physiological stress or serious arrhythmias requiring immediate intervention. Early differentiation between sinus tachycardia, supraventricular tachycardia (SVT), and ventricular tachycardia (VT) is essential to ensure timely, appropriate treatment.
Key Objectives
- Differentiate between sinus tachycardia, SVT, and VT based on ECG features.
- Assess for hemodynamic stability.
- Apply evidence-based interventions including vagal maneuvers, medications, or synchronized cardioversion.
Recognition: Differentiating Tachycardia Types
| Tachycardia Type | Rate | Rhythm | P Waves | QRS Duration | Clinical Clues |
|---|---|---|---|---|---|
| Sinus Tachycardia | <220 bpm (infants), <180 bpm (children) | Regular | Present | Narrow | Responsive to fluid, fever control |
| SVT | >220 bpm (infants), >180 bpm (children) | Regular | Absent or hidden | Narrow | Sudden onset, poor perfusion, no rate variability |
| Ventricular Tachycardia | Variable | Regular | Absent | Wide (>0.09 sec) | May cause hypotension, possible progression to VF |
Step-by-Step Management
Step 1: Assess for Hemodynamic Stability
If the child has poor perfusion (lethargy, hypotension, weak pulses), this is unstable tachycardia. Proceed directly to synchronized cardioversion. If stable, continue to Step 2.
Step 2: Identify the Rhythm
- Sinus Tachycardia: Treat underlying cause—no need for antiarrhythmics or cardioversion.
- Narrow Complex Tachycardia (SVT): Try vagal maneuvers. If ineffective, give adenosine.
- Wide Complex Tachycardia (VT): Avoid adenosine. Consider amiodarone or procainamide if stable. If unstable, proceed to cardioversion.
Step 3: Synchronized Cardioversion (If Unstable)
- Initial energy: 0.5–1 J/kg synchronized shock.
- If ineffective: Increase to 2 J/kg.
- Sedation should be considered if the child is conscious and time allows.
Step 4: Medication Guidelines
- Adenosine (SVT): 0.1 mg/kg IV push (max 6 mg), followed by 0.2 mg/kg if needed (max 12 mg).
- Amiodarone (VT): 5 mg/kg IV over 20–60 min (max 300 mg).
- Procainamide: 15 mg/kg IV over 30–60 min (avoid combining with amiodarone).
Quick Reference Table
| Step | Action | Considerations |
|---|---|---|
| 1 | Assess Stability | Unstable → Cardioversion |
| 2 | Identify Rhythm | Sinus vs. SVT vs. VT |
| 3 | Vagal Maneuvers | Stable SVT only |
| 4 | Adenosine | SVT: 0.1–0.2 mg/kg IV |
| 5 | Synchronized Cardioversion | 0.5–1 J/kg, then 2 J/kg |
| 6 | Antiarrhythmics | Amiodarone or procainamide for VT |
Escalation Criteria
- Refractory SVT → Consider beta-blockers or cardioversion.
- Refractory VT → Consult cardiology; evaluate for underlying causes (e.g., myocarditis, WPW).
- Suspected WPW → Avoid AV node blockers (adenosine, digoxin, calcium channel blockers).
Signs of Clinical Improvement
- Heart rate within normal limits for age.
- Strong peripheral pulses and normal perfusion.
- Improved mental status and oxygenation.
- Stable blood pressure and respiratory effort.
Summary
- Differentiate sinus tachycardia from SVT or VT before initiating treatment.
- Unstable rhythms require synchronized cardioversion—don’t delay.
- Use adenosine only for narrow-complex, stable SVT.
- Treat VT with antiarrhythmics or cardioversion, not adenosine.
Takeaway: Rapid recognition and management of pediatric tachycardia can prevent progression to cardiac arrest. Know your rhythms, act fast, and treat appropriately.