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.