II. Precautions

  1. Distinguish SVT from Sinus Tachycardia (see Supraventricular Tachycardia for distinguising features)
  2. Do not use this algorithm for Sinus Tachycardia
  3. Always obtain an EKG after conversion to a sinus rhythm to asess for underlying causes
    1. WPW Syndrome
    2. Brugada Syndrome
    3. Prolonged QT Interval
  4. Combining Antiarrhythmics risks complications
    1. Avoid using both Amiodarone and Procainamide
    2. Verapamil can also predispose to complications when used in combination with Amiodarone or Procainamide

III. Labs

  1. Avoid Cardiac Markers (e.g. Troponin, BNP) in children with SVT
    1. Markers will be increased in PSVT
  2. Other labs (e.g. Electrolytes)
    1. Not indicated in most cases of PSVT unless suspected secondary cause

IV. Diagnostics

  1. Electrocardiogram
    1. Indicated in all patients after SVT termination
    2. Evaluate for signs WPW (Delta wave or Short PR Interval)
      1. See restrictions below

V. Imaging

  1. Chest XRay
    1. Not indicated in typical SVT
  2. Echocardiogram indications
    1. Adolescents (prior to Cardiac Ablation)
    2. Infants with Supraventricular Tachycardia

VI. Management: Initial Stable SVT

  1. Vagal Stimulation (if no delay)
    1. See Vagal Maneuver
    2. Ice water immersion or ice placed on face
    3. Carotid Massage
    4. Valsalva Maneuver
      1. See Valsalva for positional modifications (increased efficacy)
  2. Adenosine (if no delay)
    1. Precautions
      1. Do not use Adenosine in irregular rhythm (risk of rhythm degeneration)
      2. Run continuous rhythm strip with Adenosine to interpret response and underlying rhythm
    2. First: 0.1 mg/kg rapid IV push (maximum: 6 mg)
    3. Second: 0.2 mg/kg rapid IV push (maximum: 12 mg)
      1. Indicated if no response to first dose other than transient rate slowing
      2. Second dose not beneficial if rhythm terminated with first Adenosine dose and then recurred
        1. In these cases, see Verapamil below
  3. Verapamil
    1. Precautions
      1. Avoid Verapamil under age 2-5 years or Wide Complex Tachycardia, WPW or CHF
    2. Indications
      1. SVT converts with Verapamil and then recurs
      2. Verapamil is more helpful than Adenosine in these cases (one hour duration instead of seconds for Adenosine)

VII. Management:

  1. Indications
    1. Unstable SVT
      1. Especially in prolonged SVT (e.g. lethargic infant) in whom Antiarrhythmics may precipitate hemodynamic instability or worse Arrhythmia
    2. Failed initial measures
      1. Typically not beneficical if rhythm terminated with Adenosine dose and then recurred soon after
  2. Synchronized Cardioversion
    1. Conscious Sedation
    2. Synchronized Cardioversion
      1. Initial dose: 0.5-1.0 Joules/kg
      2. Subsequent doses: Up to 2 Joules/kg
    3. Repeat cardioversion as needed

VIII. Management: Refractory Narrow Complex Tachycardia

  1. Consult pediatric cardiology
  2. Precautions
    1. Infants presenting in SVT (especially if lethargic)
      1. Avoid Antiarrhythmics (unless directed by pediatric cardiology)
      2. Risk of precipitating Congestive Heart Failure or worse Arrhythmia
  3. Consider either of following agents based on Consultation (choose only one)
    1. Amiodarone 5 mg/kg IV over 20 to 60 minutes or
    2. Procainamide 15 mg/kg IV over 30 to 60 minutes (preferred)
      1. Greater efficacy than Amiodarone with possibly fewer adverse effects
      2. Chang (2010) Circ Arrhthm Electrophysiol 3(2): 134-40 [PubMed]

IX. Disposition: Following SVT termination

  1. Infants
    1. Admit for monitoring
    2. Cardiology Consultation
  2. Adolescent (generally healthy)
    1. Observe for 2 hours if rhythm normalized after Adenosine or Vagal Maneuvers
    2. Observe for 3-4 hours after Verapamil
    3. Admit if SVT termination required Amiodarone or Procainamide

X. Disposition: Wolff-Parkinson-White Syndrome

  1. See Wolff-Parkinson-White Syndrome
  2. Risk of Sudden Cardiac Death (0.1% per year)
  3. Cardiology Consultation
  4. Activity Restriction

XI. References

  1. Claudius, Behar and Bar-Cohen in Herbert (2014) EM:Rap 14(5): 7-8
  2. Pediatric Resucitation
    1. http://pediatrics.aappublications.org/content/126/5/e1361.full.html
    2. (2010) Pediatrics 126(5): e1361 [PubMed]

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