Disorder of Rhythm in Childreen

By : Amy Fareena Mardiana Kamal Group 93

Normal Resting Heart Rate (in beats per minute)

Newborn : 140-160 1 year : 120 5 years : 100 10 years : 80-85 15 years : 70-80

Arrhythmia
Cardiac dysrhythmia (also known as arrhythmia and irregular heartbeat) is group of conditions in which there is abnormal electrical activity of the heart heart beat may be too fast (tachycardia) or too slow (bradycardia), and may be regular or irregular. Types of arrhythmia is children includes : -Long Q-T Syndrome (LQTS) - Premature Atrial Contraction (PAC) and Premature Ventricular Contraction (PVC) - Tachycardia -Sinus Tachycardia -Supraventricular Tachycardia - Wolff-Parkinson-White Syndrome -Ventricular Tachycardia -Bradycardia -Sick Sinus Syndrome -Complete Heart Block

Long Q-T Syndrome (LQTS)

Prolong Q-T interval on ECG infrequent, hereditary disorder. May also occur in healthy people. usually affects children or young adults. Studies of otherwise healthy people with LQTS indicate that they had at least one episode of fainting by the age of 10. The majority also had a family member with a long Q-T interval.

The Q-T interval represents the time for electrical activation and inactivation of the ventricles

Signs & Symptoms

May be asymptomatic If have symptoms, child may exhibit syncope and abnormal heartbeat Patients may show prolongation of the Q-T interval during physical exercise, intense emotion or when startled by a noise. They dont necessarily have a prolonged Q-T interval all the time. Diagnosis May also result in deaf or may have congenital deafness

Diagnosis
LQTS may be suspected if there is history of sudden death in the family or repeated & unexplained episodes of fainting. diagnosis is not easy since 2.5% of the healthy population have prolonged QT interval, and 1015% of LQTS patients have a normal QT interval. LQTS "diagnostic score" may be used.

QTc (Defined as QT interval / square root of RR interval)

>= 480 msec - 3 points 460-470 msec - 2 points 450 msec and male gender - 1 point

Tordes de Pointes - 2 points T wave alternans - 1 point Notched T wave in at least 3 leads - 1 point Low heart rate for age (children) - 0.5 points Syncope (one cannot receive points both for syncope and torsades de pointes)
With stress - 2 points Without stress - 1 point

Congenital deafness - 0.5 points Family history (the same family member cannot be counted for LQTS and sudden death)
Other family members with definite LQTS - 1 point Sudden death in immediate family (members before the age 30) - 0.5 points

four or more points, the probability is high for LQTS

Managements
Arrhythmia prevention : - beta blockers - Na+ channel blockers (Mexiletin) - potassium suppliments Arrhythmia termination : - implantable cardioverter-defibrillator (ICD) on older patients & when patients have still experienced syncope even with beta blockers therapy

Premature Atrial Contraction (PAC) and Premature Ventricular Contraction (PVC)

Premature beats or extra beats most often cause irregular heart rhythms Those that start in atria are called premature atrial contractions or PAC Ventricle; Premature ventricular contractions or PVC Premature beats are very common in normal children and teenagers Premature heart beats may be perceived as a skipped heart beat, a strong beat, or a feeling of suction in the chest. Of course the heart doesnt really skipped a beat, but actually, an extra beat comes sooner than normal. Then there's usually a pause that causes the next beat to be more forceful

Usually no cause can be found and no special treatment is needed. The premature beats may disappear later. Even if they continue, the child will stay well and won't need any restrictions. Occasionally premature beats may be caused by disease or injury to the heart. So further test has to be done to make sure the childs heart is functioning well because TAC can trigger a more serious arrhythmia such as atrial flutter or atrial fibrillation On ECG, PACs are characterized by an abnormally shaped P wave PVC; S-T is much shorter Several PVCs in a row becomes a form of ventricular tachycardia (VT), which is a dangerous rapid heartbeat. This may also cause chest pain, a faint feeling, fatigue, or hyperventilation after exercise symptomatic

Treatment for symptomatic PVC

PVCs must be watched carefully, as they may cause VT Pharmacological agents : - Antiarrhythmics: these agents alter the electrophysiologic mechanisms responsible for PVCs - Beta blockers -Calcium channel blockers Electrolytes replacement : - Magnesium supplements (e.g. magnesium citrate, orotate, Maalox, etc.) - Potassium supplements

Pediatric Tachycardia
In children, the normal heart rate is age dependent, and the definition of tachycardia also varies according to age Tachycardia can be due to a physiologic response of the heart to noncardiac stimuli or to a true dysrhythmia

Cause
Hyperdynamic cardiac activity : Increased heart rate and contractility are physiologic responses to catecholamine release. Catecholamine release may occur with stress or anxiety, exercise, fever or infection, pain, anemia, seizure, hypovolemia, hypoxia, drugs or medications/stimulants, vasodilation (eg, anaphylaxis), hypoglycemia

True dysrhythmias : Supraventricular tachycardia (SVT) -Drug induced (eg, amphetamines, cocaine, caffeine, ephedrine, antihistamines, phenothiazines, antidepressants, tobacco, albuterol, theophylline, general anesthesia) -Wolff-Parkinson-White syndrome (WPW) -Hyperthyroidism -Congenital heart disease -Postoperative cardiac repair -Atrial ectopic tachycardia Atrial fibrillation or atrial flutter
Drug induced Wolff-Parkinson-White syndrome (WPW) Postoperative cardiac repair Congenital or rheumatic mitral disease Hyperthyroidism

Junctional ectopic tachycardia (JET) - Postoperative cardiac repair Ventricular tachycardia (VT)

Causes of VT includes : -Drug induced (eg, tricyclics, phenothiazines, antiarrhythmics, chloral hydrate, organophosphates, hydrocarbons, digoxin, amphetamines, cocaine, arsenic) -Prolonged Q-T syndrome/torsades de pointes -Myocarditis -Rheumatic fever -Mitral valve prolapse -Cardiomyopathy -Myocardial ischemia -Postoperative cardiac repair -Hyperkalemia (peaked T waves, prolonged QRS and QT intervals) -Hypocalcemia (increased QT intervals secondary to STsegment prolongation) -Hypokalemia (especially in association with digoxin use due to its synergistic effects on automaticity and conduction) -Hypomagnesemia (associated with hypocalcemia and hypokalemia) -Cardiac tumors -Arrhythmogenic right ventricular dysplasia

Signs&symptoms
Chest pain, Palpitations, Syncope, Dizziness, Shortness of breath, Diaphoresis (for infantswhile feeding), cyanosis, Poor peripheral perfusion, Neurologic changes (mental status, motor/sensory deficits), Decrease in intake and output, Trauma, Pain, Fever, Cardiac gallop

Diagnosis
Laboratory studies for tachycardia may include the following: - Electrolyte levels - Particularly potassium, bicarbonate, calcium, and magnesium - Blood glucose level - Complete blood count - Toxicology screen - Arterial blood gas measurement - Thyroid function tests - Urine catecholamine metabolites (homovanillic and vanillylmandelic acid)

DDX
Anemia, Chronic Atrial Fibrillation Atrial Flutter Hyperthyroidism, Thyroid Storm, and Graves Disease Hypoglycemia Pediatrics, Bacteremia and Sepsis Pediatrics, Dehydration Pediatrics, Diabetic Ketoacidosis Torsade de Pointes Toxicity, Amphetamine Toxicity, Anticholinergic Toxicity, Antidepressant Toxicity, Antihistamine Toxicity, Cocaine Toxicity, Cyclic Antidepressants Toxicity, Digitalis Toxicity, Hallucinogen Toxicity, Organophosphate and Carbamate Toxicity, Sympathomimetic Toxicity, Theophylline Toxicity, Thyroid Hormone Ventricular Tachycardia Wolff-Parkinson-White Syndrome

Treatment
Antiarrhythmic agents Adenosine, Procainamide, Digoxin, Propanolol, Amiodarone, Lidocaine goals of pharmacotherapy are to reduce morbidity and prevent complications

Supraventricular Tachycardia
The most common abnormal tachycardia in children also called paroxysmal atrial tachycardia (PAT) or paroxysmal supraventricular tachycardia (PSVT) The fast heart rate involves both atrial & ventricle. This isn't a life-threatening problem for most children and adolescents. Treatment is only considered if episodes are prolonged or frequent. For many infants, SVT is a time-limited problem. Treatment with medications often stops after six to 12 months.

SVT may occur in very young infants with otherwise-normal hearts. The heart rate is usually more than 220 beats a minute. Infants with an SVT episode may breathe faster than normal and seem fussy or sleepier than usual. This situation must be diagnosed and treated to return the heart rate to normal. Once the rhythm is normal, medication usually can prevent future episodes. Sometimes SVT can be detected while a baby is still in the womb. Then the mother may take medications to slow her baby's heart rate.

If an older infant or child has SVT, the child may be aware of the rapid heart rate. This may be associated with palpitations, dizziness, lightheadedness, chest discomfort, upset stomach or weakness. Valsalva maneuver - children can learn ways to slow down their heart rate using this method. Older children are more likely to have more episodes of tachycardia. They're more likely to need prolonged treatment. They also may need more diagnostic tests

cause
Drug induced (eg, amphetamines, cocaine, caffeine, ephedrine, antihistamines, phenothiazines, antidepressants, tobacco, albuterol, theophylline, general anesthesia) Wolff-Parkinson-White syndrome (WPW) Hyperthyroidism Congenital heart disease Postoperative cardiac repair Atrial ectopic tachycardia

Signs & Symptoms

Pounding heart Shortness of breath Chest pain Rapid breathing Dizziness Loss of consciousness (in serious cases) Numbness of various body parts

Diagnosis
ECG beat can be count and most have narrow QRS complex

Management
Physical maneuver - activation of the parasympathetic nervous system by Valsalva maneuver - other vagal maneuvers including: holding ones breath for a few seconds, coughing, plunging the face into cold water,drinking a glass of ice cold water, and standing on one's head. Also Carotid sinus massage

Pharmacology - Adenosine, an ultra short acting AV nodal blocking agent, is indicated if vagal maneuvers are not effective. - If this works, followup therapy with diltiazem, verapamil or metoprolo l may be indicated. - SVT that does not involve the AV node may respond to other antiarrhythmic drugs such as sotalol or amiodarone.

Cardioversion - Also called electrical countershock - If the patient is unstable or other treatments have not been effective. - small catheter (a thin, flexible tube) is placed through the nostril into the esophagus. A small amount of electricity is sent through this catheter giving a small electrical shock to the chest wall. This is effective to stop the SVT.

Wolff-Parkinson-White syndrome
congenital abnormality involving the presence of abnormal conductive tissue between the atria and the ventricles in association with supraventricular tachycardia (SVT) involves preexcitation, which occurs because of conduction of an atrial impulse not by means of the normal conduction system, but via an extra atrioventricular (AV) muscular connection, termed as accessory pathway (AP), that bypasses the AV node

Clinical Presentation
Patients with Wolff-Parkinson-White (WPW) syndrome may present with anything from mild chest discomfort or palpitations with or without syncope to severe cardiopulmonary compromise or cardiac arrest infant may frequently be irritable, may not tolerate feedings, or may demonstrate evidence of congestive heart failure verbal child with WPW syndrome usually reports chest pain, palpitations, or breathing difficulty

Diagnosis
Classic ECG

short PR (< 120 ms) ,

QRS >120 ms with a slurred onset of the QRS waveform producing a delta wave in the early part of QRS

Characteristic delta wave

Management
Radio frequency ablation (RFA) ablation of the accessory pathway [AP] antiarrhythmic drugs slowing AP conduction, or AV blockers to slow AV nodal conduction ca+ channel blockers (verapamil, diltiazem) Beta blockers metoprolol, atenolol

Congenital complete heart block

Third-degree congenital atrioventricular block (CAVB) is usually a complete heart block (ventricular impulses slower than and dissociated from the atrial rhythm) seen in a fetus or at an early age may be present at or even before birth 2 types - isolated CAVB (structurally normal heart) - complex CAVB (congenital heart defects)

etiology
CAVB with structural heart disease is considered to be caused by failure of the AV conduction system to develop during heart development. This may be a result of increased distance between the AV node and the ventricular conduction tissues, as when associated with structural congenital heart disease or damage related to the passage of maternal autoantibodies But for isolated CAVB, theres no clear etiology

Clinical presentation
Mother may be asymptomatic. But fetus in prenatal period usually presents with bradycardia or hydrops fetalis. Usually this is found out by accident, or if siblings have heart block (17% re-occurrence in family members) Newborns with congenital heart block may present with a hydropic appearance, may develop signs of low cardiac output or cardiac failure few hours or few days after birth In older childern; pallor, mottling, lethargy, exercise intolerance, palpitations, dizziness, or syncope,

Diagnosis
ECG long QT Children more than 7yrs old may be tested using stress test Chest radiography can reveal cardiomegaly and pleural effusions may also be identified during prenatal examinations, in the perinatal period, or during childhood or adulthood

Management
Medications arent nessecary for children with this dz Currently, medical care for children with complete heart block is focused on the optimal timing to place a pacemaker. Pacemaker is to ensure positive outcome and to ensure the child could live normaly because in serious cases (eg when syncope is present), sudden death may occur In emergency cases, chronotropic medications, with or without inotropic agents, may be helpful in fetuses and newborns with hydrops fetalis, congestive heart failure, or low cardiac output

References
http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Types-ofArrhythmia-in-Children_UCM_302023_Article.jsp#.TslBppWP_QB http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/AF-andChildren_UCM_423774_Article.jsp#.TskOzpWP_QA http://en.wikipedia.org/wiki/Cardiac_dysrhythmia http://en.wikipedia.org/wiki/Premature_atrial_contraction http://en.wikipedia.org/wiki/Premature_ventricular_contraction http://en.wikipedia.org/wiki/Long_QT_syndrome http://www.emedicinehealth.com/heart_rhythm_disorders/article_em.htm http://www.nlm.nih.gov/medlineplus/ency/article/003399.htm http://pediatrics.aappublications.org/content/96/1/122 http://pediatrics.aappublications.org/content/26/3/402.short