Pediatric Advanced Life Support - PALS Core Testing Case Scenario 10: Wide-Complex Tachycardia Possible Ventricular Tachycardia (Infant; Stable)
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.
Heart Rate 220/min
Blood Pressure 96/54 mm Hg
Respiratory Rate 36/min
SpO2 97% while receiving 30% oxygen by face mask
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.
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
No immediate intervention needed
Proceed to Primary Assessment
Evaluate - Primary Assessment
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
Weight: 6 kg
Wide complex tachycardia (possible VT) with a pulse and adequate perfusion (stable)
Regular monomophric complexes
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
Signs and symptoms: Fussy; agitated since early morning
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
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
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
Persistent stable, wide complex tachycardia with a pulse and adequate perfusion
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
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
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.