arrhythimias 2

8/6/2019 Arrhythimias 2

1/54


2/54

Cardiac Arrhythmias inCardiac Arrhythmias in

infants & childreninfants & children

Dr Aly MA ELDr Aly MA EL--Mohsen, MDMohsen, MD

Lecturer in Pediatrics,Lecturer in Pediatrics,Alexandria UniversityAlexandria University


3/54

Impulse formation & conductionImpulse formation & conduction


4/54

Recording ECGRecording ECG

Limb Leads (I , II, III)Limb Leads (I , II, III)

Augmented leads (avL, avR, avF)Augmented leads (avL, avR, avF)

Chest (precordial) leads (VChest (precordial) leads (V11VV66))


5/54

Limb leadsLimb leads


6/54

Augmented leadsAugmented leads


7/54

Precordial leadsPrecordial leads


8/54

Waves, intervals & segmentsWaves, intervals & segments


9/54

++++++++++++++++++++++++++++++++++++++- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -++++++++++++++++++++++++++++++++++++++

I, II, III,

avL,

avF

V3-6

avR

V 1-2Na+

K+


10/54

ECG wave GenerationECG wave Generation


11/54

Wave generation continuedWave generation continued


12/54



13/54



14/54

Cardiac cycleCardiac cycle


15/54

Estimation of the HREstimation of the HR

300

Number of large squaresHR=


16/54

Finding theP

waveFinding theP

wave


17/54


18/54

Aetiology of arrhythmiasAetiology of arrhythmias

Congenital heart diseases.Congenital heart diseases.

Myocarditis (e.g. viral myocarditis)Myocarditis (e.g. viral myocarditis)

Cardiomyopathy.Cardiomyopathy. PostPost--operatively.operatively.

DrugDrug--induced (e.g. digitalis).induced (e.g. digitalis).

Electrolyte disturbances.Electrolyte disturbances.

Endocrinal & metabolic diseases.Endocrinal & metabolic diseases.

Cardiac tumours (rhabdomyoma or myxoma)Cardiac tumours (rhabdomyoma or myxoma)


19/54

Arrhythmia

Abnormal impulse

formation

Abnormal impulse

conduction


20/54


21/54

Abnormal impulse formationAbnormal impulse formation

Supraventricular

Sinus tachycadia.

Sinus bradycardia.

Premature atrial complexes

Supraventriculartachycardia.

Junctional rhythmortachycardia.

Atrial flutter& fibrillation.

Ventricular

Premature ventricularcomplexes.

Ventriculartachycardia.

Ventricularfibrillation.


22/54

Sinus TachycardiaSinus Tachycardia


23/54

Sinus tachycardiaSinus tachycardia


24/54

Sinus bradycardiaSinus bradycardia


25/54


26/54

Premature atrial complexesPremature atrial complexes


27/54

APCs continuedAPCs continued

Blocked PACs


28/54

SupraventricularTachycardia

Automatic Reentry

Ectopic atrial tachy. AV node Accessory

pathway


29/54

Reentry TachycardiaReentry Tachycardia


30/54

Supraventricular TachycardiaSupraventricular Tachycardia

The most frequent sustained arrhythmia inThe most frequent sustained arrhythmia in

pediatrics.pediatrics.

May start to occur inMay start to occur in--utero, neonatal, infancy orutero, neonatal, infancy orchildhood.childhood.

HR is regular & rapidHR is regular & rapid 240240--300300 bpm.bpm.

Attacks starts suddenly & last for period of fewAttacks starts suddenly & last for period of fewseconds up to several weeks.seconds up to several weeks.

Heart failure may eventually occur.Heart failure may eventually occur.


31/54


32/54


33/54

1212--lead ECG (SVT)lead ECG (SVT)


34/54

Clinical features ofSVTClinical features ofSVT

In newborn & infants:In newborn & infants:

Sudden pallor, tachyapnea & refusal of feeding.Sudden pallor, tachyapnea & refusal of feeding.

Baby is usually restless & very irritable.Baby is usually restless & very irritable.

Very rapid HR with cardiomegaly & hepatomegaly.Very rapid HR with cardiomegaly & hepatomegaly.

In older children:In older children:

Child may be aware of the onset of the fast heartChild may be aware of the onset of the fast heartrate & become anxious & apprehensive.rate & become anxious & apprehensive.


35/54

Treatment ofSVTTreatment ofSVT

Vagal stimulation.Vagal stimulation.

Adenosine: (adenocorAdenosine: (adenocor 33mg/ml)mg/ml)

IVIV 5050 100100 mcg/kg , can be repeated/mcg/kg , can be repeated/22min withmin with 5050mcg/kg increase in dose up tomcg/kg increase in dose up to 33 times.times.

Digitalis:Digitalis:

Digitalization atDigitalization at 00..0202 00..035035 mg/kg/daymg/kg/day 33 doses IV.doses IV. maintenance :maintenance : 00..0101 mg/kg/daymg/kg/day 22dose orallydose orally (for(for 11 year)year)

NOT in WPW


36/54

Treatment ofSVT continuedTreatment ofSVT continued

Beta blockers:Beta blockers:

Inderal (propranolol)Inderal (propranolol)

IV slowlyIV slowly 00..0202 -- 00..0505 mg/kg can be repeated/mg/kg can be repeated/ 66--88

hrs.hrs.

OrallyOrally 00..22 00..55 mg/kg t.d.s for maintenance.mg/kg t.d.s for maintenance.

Esmolol : (brevibloc)Esmolol : (brevibloc)

IV bolusIV bolus 00..55 mg/kg thenmg/kg then 5050 mcg/kg/min IVmcg/kg/min IV

infusion.infusion.


37/54

AmiodaroneAmiodarone: (cordarone): (cordarone)

IVIV 55mg/kg overmg/kg over 2020 minutes followed byIVminutes followed byIV

infusion ofinfusion of 00..33 00..99 mg /kg/hr.mg /kg/hr.

OrallyOrally 55 mg /kg twice daily formg /kg twice daily for 77--1010 days thendays then 55--1010/kg daily./kg daily.

FlecainideFlecainide::

IVIV 22 mg/kg overmg/kg over 1010 --3030 mins thenmins then 00..11 --00..22mg/kg/hr until arrhythmia stops.mg/kg/hr until arrhythmia stops.

OrallyOrally 22 mg /kgmg /kg 22--33 times daily.times daily.



38/54

VerapamilVerapamil : (in older children): (in older children)

IV:IV:Given overGiven over 2233 minutes in dose ofminutes in dose of 00..1100..33mg/kg, using continuous ECG monitoring. Maymg/kg, using continuous ECG monitoring. May

repeat once afterrepeat once after 3030 mins.mins. max dose:max dose: 55 mg.mg.

PO: Children:PO: Children:4488 mg/kg/mg/kg/2424 hrhr TIDTID

DC shock:DC shock:

For unresponsive hemodynamically compromisedFor unresponsive hemodynamically compromisedinfants & children with SVT.infants & children with SVT.

00..5522 wattwatt--sec/kg.sec/kg.



39/54

TwentyTwenty--four hour electrocardiographic (Holter)four hour electrocardiographic (Holter)recordingsrecordings are useful in monitoring the course ofare useful in monitoring the course oftherapy and in detecting brief runs of asymptomatictherapy and in detecting brief runs of asymptomatictachycardia .tachycardia .

Radiofrequency ablationRadiofrequency ablation of an accessory pathway :of an accessory pathway :11-- multiple agents are required ormultiple agents are required or22-- drug side effects are intolerabledrug side effects are intolerable33-- arrhythmia control is poor.arrhythmia control is poor.

The overall initial success rate ranges from approximatelyThe overall initial success rate ranges from approximately8080% to% to 9595%, depending on the location of the bypass%, depending on the location of the bypasstract or tracts.tract or tracts.



40/54


41/54

Premature Ventricular ComplexesPremature Ventricular Complexes

Dangerous types:

(1) two or more ventricular premature beats in a row.

(2) multifocal origin.(3) increased ventricular ectopic activity with exercise.

(4) R on T phenomenon (PVC occurs on the T wave of the preceding beat).

(5) Presence of underlying heart disease


42/54

Premature Ventricular ComplexesPremature Ventricular Complexes


43/54

Ventricular TachycardiaVentricular Tachycardia


44/54

Ventricular tachycardia

SVT


45/54

1212--lead ECG (VT)lead ECG (VT)


46/54


47/54

VT

SVT


48/54

Treatment of Vent arrhythmiasTreatment of Vent arrhythmias

Lidocaine:Lidocaine:

IVIV 00..55 11 mg /kg thenmg /kg then 00..66 33 mg/kg/hr bymg/kg/hr byinfusion.infusion.

Amiodarone intravenously.Amiodarone intravenously.

DC shock (DC shock (00..5522 wattwatt--sec/kg) .sec/kg) .


49/54


50/54

Viral MyocarditisViral Myocarditis

EtiologyEtiology:: Coxsackie B virus.Coxsackie B virus.

AdenovirusAdenovirus

ClinicallyClinically:: Breathlessness on exertion & feeding.Breathlessness on exertion & feeding.

Excessive sweating.Excessive sweating.

Irritability & weak cry.Irritability & weak cry.

T

achycardiaT

achycardia Tachyapnea.Tachyapnea.

Gallop rhythm.Gallop rhythm.


51/54

Enlarged tender liver.Enlarged tender liver.

Edema.Edema.

CXRCXR::

Cardiomegaly.Cardiomegaly.

Congested lung fields.Congested lung fields.

ECGECG::

Low voltage ECG.Low voltage ECG.

ST segment changes.ST segment changes.


52/54

TreatmentTreatment::

Diuretics.Diuretics.

Digitalis.Digitalis.

Captopril.Captopril.


53/54


54/54

arrhythimias 2

Documents