Posted by American Heart Association, Inc. on Jan 11th 2020
Pediatric Advanced Life Support - PALS Core Testing Case Scenario 10: Wide-Complex Tachycardia Possible Ventricular Tachycardia (Infant; Stable)
Pediatric Advanced Life Support - PALS Core Testing Case Scenario 10: Wide-Complex Tachycardia Possible Ventricular Tachycardia (Infant; Stable)
Scenario Lead-in
Prehospital: You are en route to a call for a 3 month old infant with irritability and cold like symptoms.
ED: You are called to the emergency department to help out with a 3 month old infant with irritability and cold like symptoms.
General Inpatient Unit: You are called to the bedside of a 3 month old infant who was admitted with irritability and cold like symptoms.
ICU: You are called to see a 3 moth old infant who was admitted to the intensive care unit for a respiratory distress episode earlier in the day.
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Heart Rate 220/min
Blood Pressure 96/54 mm Hg
Respiratory Rate 36/min
SpO2 97% while receiving 30% oxygen by face mask
Temperature Afebrile
Weight 6 kg
Age 3 months
Scenario Overview and Learning Objectives
Scenario Overview: Emphasis should be the recognition of wide-complex tachycardia in a stable patient and consideration of adenosine (if rhythm regular and QRS is monomorphic). In addition, providers should search for and treat reversible causes (eg, hypokalemia or hyperkalemia). Provision of synchronized cardioversion and administration of antiarrhythmics are beyond the scope of this scenario, but discussion regarding indications for synchronized cardioversion, including appropriate dose and safe delivery, should occur after completing the scenario. Expert consultation with a pediatric cardiologist is strongly recommended before such interventions because expertise is required to minimize potential negative hemodynamic effects.
Scenario-Specific Objectives
Differentiates between ventricular tachycardia (VT) and supraventricular tachycardia (SVT) with a pulse and poor perfusion; in this scenario, the child’s wide complex tachycardia is probably VT.
Differentiates between pulseless VT and wide complex tachycardia (possible VT) with pulse
Describes the indications for synchronized cardioversion in VT; in this scenario, the infant has respiratory distress but no hypotension, acutely altered mental status or signs of shock, so does not require immediate synchronized cardioversion.
Discussed possible administration of adenosine; in this scenario, the wide complexes are in regular rhythm and QRS morphology is monomorphic, so adenosine can be considered.
Describes safe delivery of synchronized cardioversion (if needed) with appropriate dose in an infant with VT and a pulse
Discusses reason that expert consultation is advised before performing synchronized cardioversion in a stable child with VT
Evaluate - Initial Impression (Pediatric Assessment Triangle)
Appearance: Awake; crying
Breathing: Spontaneous; nasal congestion; no increased work of breathing apparent
Circulation: Pale skin
Identify:
No immediate intervention needed
Intervene:
Proceed to Primary Assessment
Evaluate - Primary Assessment
Airway: Crying
Breathing: Upper airway congestion; bilateral air entry; no use of accessory muscles; no nasal flaring; respiratory rate 36/min; Spo2 97% when receiving 30%oxygen by face mask
Circulation: Heart rate 220/min; blood pressure 96/54 mm Hg; pale skin; capillary refill 3 seconds; strong central pulses, palpable peripheral pulses; QRS complexes are regular and monomorphic
Disability: Awake; fussy; eyes open
Exposure: Afebrile;
Weight: 6 kg
Identify:
Wide complex tachycardia (possible VT) with a pulse and adequate perfusion (stable)
Regular monomophric complexes
Intervene:
Activate the emergency response system. Emergency medical services requests additional assistance if needed.
Administer supplementary oxygen if needed.
Apply cardiac monitor.
Apply pulse oximeter.
Identify rhythm: wide complex tachycardia (possible VT) with a pulse and adequate perfusion.
Obtain 12 lead electrocardiogram (ECG)
Search for and treat reversible causes.
Obtain Vascular access (intravenous IV)
Consider adenosine administration
-Record continuous rhythm strip during administration
-Give adenosine 0.1mg/kg, rapid IV push (max 6 mg)
-If first dose of adenosine is unsuccessful, administer adenosine 0.2 mg/kg, rapid IV push (max 12 mg). Ensure that rapid push administration technique is used to administer the drug.
-If adenosine is ineffective, seek expert consultation.
Evaluate - Secondary Assessment
SAMPLE history
Signs and symptoms: Fussy; agitated since early morning
Allergies: None
Medications: None
Past medical history: Delivery at 39 week; no problems
Last meal: 1 oz formula 4 hours ago
Events: Admitted to floor 6 hours ago with fussiness, agitation, symptoms
Physical examination:
Repeat vital signs (adenosine has no effect): Heart rate 218/min (wide complex tachycardia persists); blood pressure 96/56 mm Hg; respiratory rate 24/min; Spo2 97% on room air
Head, eyes, ears, nose, throat/neck: Normal
Heart and lungs: No murmur, gallop, or rub; lungs clear; capillary refill 3 seconds; peripheral pulses weak
Abdomen: Nondistended; nontender; no masses; normal bowel sounds; no hepatomegaly
Extremities: No edema; no rash; cool hands and feet
Back: Normal
Neurologic: Pupils equal and reactive equal
If sedation and/or cardioversion undertaken without expert consultation
Vital signs: heart rate 218/min; wide complex tachycardia persists; blood pressure 64/35 mm Hg; development of signs of heart failure and poor perfusion
Identify
Persistent stable, wide complex tachycardia with a pulse and adequate perfusion
Intervene
Monitor cardiorespiratory function for signs of heart failure (enlarged live, extra heart sounds or murmurs, crackles/rales.
Search for and treat reversible causes.
Obtain 12 lead ECG
Wean supplementary oxygen as tolerated
Evaluate - Diagnostic Assessments
Perform Throughout the Evaluation of the Patient as Appropriate
Lab data
Blood glucose
Electrolytes
A blood gas (arterial, venous, or capillary blood gas) not indicated in the immediate management of this infant, but could be considered after stabilization to guide further management
Imaging
Not indicated
Identify/Intervene
Although laboratory test are generally not appropriate during the immediate management, a blood glucose concentration should be checked with point of care testing as soon as reasonable in all critically ill children. Hypoglycemia should be treated immediately.
Serum electrolytes should also be checked as soon as possible. An electrolyte abnormality such hypokalemia or hyperkalemia may cause ventricular arrhythmias.