Cardiac Arrhythmias

in infants & children

Dr Aly MA EL-Mohsen, MD
Lecturer in Pediatrics,
Alexandria University
Impulse formation & conduction
 Recording ECG

 Limb Leads (I , II, III)

 Augmented leads (avL, avR, avF)

 Chest (precordial) leads (V1 – V6)

Limb leads
Augmented leads
Precordial leads
Waves, intervals & segments
avR
V 1-2 ,I, II, III
+
Na
avL,
avF
V3-6
-+++++++++++++++++++++++++++++++++++++
-----------------------------------
+
+
K

+++++++++++++++++++++++++++++++++++++
------------------------------------
+
ECG wave Generation
Wave generation continued
Wave generation continued
Wave generation continued
Cardiac cycle
Estimation of the HR

300
= HR
Number of large squares
Finding the P wave
 Aetiology of arrhythmias
 Congenital heart diseases.
 Myocarditis (e.g. viral myocarditis)
 Cardiomyopathy.
 Post-operatively.
 Drug-induced (e.g. digitalis).
 Electrolyte disturbances.
 Endocrinal & metabolic diseases.
 Cardiac tumours (rhabdomyoma or myxoma)
 Arrhythmia

Abnormal impulse Abnormal impulse

formation conduction
 Abnormal impulse formation

Supraventricular Ventricular
• Sinus tachycadia. • Premature ventricular complexes.

• Sinus bradycardia. • Ventricular tachycardia.

• Premature atrial complexes • Ventricular fibrillation.
• Supraventricular tachycardia.
• Junctional rhythm or tachycardia.
• Atrial flutter & fibrillation.
Sinus Tachycardia
Sinus tachycardia
Sinus bradycardia
Premature atrial complexes
APCs continued

Blocked PACs
 Supraventricular
Tachycardia

Automatic Reentry

Ectopic atrial AV node Accessory

tachy. pathway
Reentry Tachycardia
 Supraventricular Tachycardia
 The most frequent sustained arrhythmia in
pediatrics.
 May start to occur in-utero, neonatal, infancy
or childhood.
 HR is regular & rapid 240-300 bpm.
 Attacks starts suddenly & last for period of
few seconds up to several weeks.
 Heart failure may eventually occur.
lead ECG (SVT)-12
 Clinical features of SVT
 In newborn & infants:
 Sudden pallor, tachyapnea & refusal of feeding.
 Baby is usually restless & very irritable.

 Very rapid HR with cardiomegaly &

hepatomegaly.
 In older children:
 Child may be aware of the onset of the fast heart
rate & become anxious & apprehensive.
 Treatment of SVT
 Vagal stimulation.

 Adenosine: (adenocor 3mg/ml)

 IV 50 – 100 mcg/kg , can be repeated/2min with 50
mcg/kg increase in dose up to 3 times.

 Digitalis: NOT in WPW

 Digitalization at 0.02 – 0.035 mg/kg/day ÷ 3 doses IV.
 maintenance : 0.01 mg/kg/day ÷ 2 dose orally (for 1
year)
 Treatment of SVT continued

 Beta blockers:
 Inderal (propranolol)
 IV slowly 0.02 - 0.05 mg/kg can be repeated/ 6-8
hrs.
 Orally 0.2 – 0.5 mg/kg t.d.s for maintenance.

 Esmolol : (brevibloc)
 IV bolus 0.5 mg/kg then 50 mcg/kg/min IV infusion.
 Treatment of SVT continued

 Amiodarone: (cordarone)
 IV 5mg/kg over 20 minutes followed by IV
infusion of 0.3 – 0.9 mg /kg/hr.
 Orally 5 mg /kg twice daily for 7-10 days then 5-
10 /kg daily.
 Flecainide:
 IV 2 mg/kg over 10 -30 mins then 0.1 -0.2
mg/kg/hr until arrhythmia stops.
 Orally 2 mg /kg 2-3 times daily.
 Treatment of SVT continued

 Verapamil : (in older children)

 IV: Given over 2–3 minutes in dose of 0.1–0.3
mg/kg, using continuous ECG monitoring. May
repeat once after 30 mins. max dose: 5 mg.
 PO: Children: 4–8 mg/kg/24 hr ÷ TID

 DC shock:
 For unresponsive hemodynamically compromised
infants & children with SVT.
 0.5–2 watt-sec/kg.
 Treatment of SVT continued

 Twenty-four hour electrocardiographic (Holter)

recordings are useful in monitoring the course of
therapy and in detecting brief runs of asymptomatic
tachycardia .
 Radiofrequency ablation of an accessory pathway :
1- multiple agents are required or
2- drug side effects are intolerable
3- arrhythmia control is poor.
The overall initial success rate ranges from
approximately 80% to 95%, depending on the
location of the bypass tract or tracts.
Premature Ventricular Complexes

:Dangerous types
.two or more ventricular premature beats in a row )1(
.multifocal origin )2(
.increased ventricular ectopic activity with exercise )3(
.R on T phenomenon (PVC occurs on the T wave of the preceding beat) )4(
Presence of underlying heart disease )5(
Premature Ventricular Complexes
Ventricular Tachycardia
Ventricular tachycardia

SVT
lead ECG (VT)-12
VT

SVT
 Treatment of Vent arrhythmias
 Lidocaine:
 IV 0.5 – 1 mg /kg then 0.6 – 3 mg/kg/hr by
infusion.
 Amiodarone intravenously.
 DC shock (0.5–2 watt-sec/kg) .
 Viral Myocarditis
 Etiology:
 Coxsackie B virus.
 Adenovirus
 Clinically:
 Breathlessness on exertion & feeding.
 Excessive sweating.
 Irritability & weak cry.
 Tachycardia
 Tachyapnea.
 Gallop rhythm.
  Enlarged tender liver.
 Edema.

 CXR:
 Cardiomegaly.
 Congested lung fields.

 ECG:
 Low voltage ECG.
 ST segment changes.
 Treatment:
 Diuretics.
 Digitalis.
 Captopril.