Narrow Complex Tachyarrhythmia

Assessment

Pediatric Pearls: Signs & Symptoms: Differential: 
□ Use approved reference document for medication dosing, electrical therapy, and equipment sizes. 
□ Focus on rapid and early BLS airway and ventilation tools. Intubation may not be the best option for these patients. 
□ Pediatric pads should be used in children < 25 Kg. 
□ Consider SVT with HR >180 in children 		□ QRS < 0.12 sec 
□ Pale or Cyanosis 
□ Diaphoresis 
□ Tachypnea 
□ Vomiting 
Hypotension 
□ Altered Level of Consciousness 
□ Pulmonary Congestion 
□ Syncope		□ Heart disease (WPW, Valvular) 
□ Sick sinus syndrome 
□ Myocardial infarction 
□ Electrolyte imbalance 
□ Exertion, pain, emotional stress 
□ Fever 
□ Hypoxia or Anemia 
□ Hypovolemia 
□ Drug effect / Overdose 
□ Hyperthyroidism 
□ Pulmonary embolus 
□ Alcohol withdrawal 

Clinical Management Options

EMT-B
• Oxygen PRN titrated to SpO2 92%-96% 
• Basic airway management 
Paramedic
• Vascular access 
• Obtain EKG
• Monitor ETCO2
• Vascular access 
• Isotonic Crystalloid PRN titrated to SBP > 100 mmHg or MAP > 65 
• For SVT
• Have the patient perform a valsava maneuver
• Ice to the face in infants can be effective
• Consider adenosine (monitor EKG during adenosine use)
• If the patient becomes unstable, perform a synchronized cardioversion at maximum joules
• Pediatric Synchronized Cardioversion 1.0 j/kg, repeat as needed at 2 j/kg 
• Obtain a new EKG after cardioversion
• For afib/aflutter, consider Magnesium (may cause hypotension so use with caution)
• For tachycardia, treat the underlying cause of tachycardia
Consult Online Medical Control as Needed

Pearls

  • Sinus tachycardia may be misinterpreted as SVT or A-fib. Sinus tach >150 (adult) or >180 (pediatric) may be seen in the septic patient.
    • Obtaining a full EKG can help determine the underlying rhythm
  • Use caution in patient currently on antihypertensive medication. 
  • Adenosine may not be effective in identifiable atrial flutter / fibrillation but is not harmful. 
  • Cardioverting afib/aflutter can potentially cause a stroke. Do not attempt to cardiovert stable afib/aflutter.
  • Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. 
  • Continuous pulse oximetry is required for all atrial fibrillation patients. 
  • Narrow complex tachycardia in setting of alcohol withdrawal should be treated aggressively with midazolam. If SVT is “exquisitely regular”, any heart rate variability should lead you to consider sinus tachycardia or atrial fibrillation. 
  • Consider a change of vector of initial cardioversion is unsuccessful to anterior/posterior pad placement.