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Paediatric Tachycardia Management Algorithm

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The treatment of all patients in distress begins with the basics.  Tachycardia is no different.
  • Oxygen if indicated by pulse oximetry less than 95% or shortness of breath
  • Maintain airway
  • Place the patient on the cardiac monitor
  • Monitor vital signs, including oximetry
  • IV or IO Access
  • 12 Lead ECG to assist with diagnosis if the condition of the patient permits (Do not delay emergent treatment)
The treatment of tachycardia is based on the type of tachycardia.  There are three possible types.  Narrow Complex Tachycardia which is further divided into Sinus Tachycardia and Supraventricular Tachycardia and Wide Complex Tachycardia (possible Ventricular Tachycardia).
Narrow Complex Tachycardia must have a QRS duration less than 0.1 seconds.

Sinus Tachycardia

  • Diagnosis is often based upon history.  This patient will have a history consistent with a known cause that requires compensation.  For example, dehydration, pain, hypovolemia.
  • P waves are normal, Rhythm is regular and rate is usually less than 220  per minute in infants and 180 in children.
  • TREATMENT:  Find and treat the underlying cause.  For example, in dehydration replace fluid; treat pain, etc.

Supraventricular Tachycardia

  • History is vague
  • P waves are absent or abnormal looking, Heart rate is usually greater than 220 in infants and greater than 180 in children
  • TREATMENT:  If IV or IO is available, give Adenosine 0.1mgkg rapid bolus (maximum of 6mg)  This can be repeated with a second dose of 0.2mg/kg rapid bolus (maximum of 12mg)
  • If Adenosine is unsuccessful, or IV/IO access is not available synchronized cardioversion is indicated
    • Start at 0.5-1.0 J/kg – if not effective increase to 2 joules/kg 
    • Sedate if needed but do not delay treatment

Wide Complex Tachycardia (QRS >0.9secs) – Probable Ventricular Tachycardia

Always begin with the basics. 
  • If the child is hypotensive, has acute altered level of consciousness or signs of shock IMMEDIATE SYNCHRONIZED CARDIOVERSION is indicated.
    • 0.5 Joules/kg
    • 2 Joules/kg
  • If no hypotension, altered level or signs of shock and the rhythm is regular with monomorphic (all QRSs look alike) consider using Adenosine
    • Adenosine 0.1mg/kg rapid IV bolus Maximum of 6mg
    • Adenosine 0.2mg/kg rapid IV bolus Maximum of 12mg
  • If no hypotension, altered level or signs of shock Consult an expert (Cardiology or Electrophysiology) who will consider
    • Amiodarone 5mg/kg IV/IO over 20-60 minutes OR
    • Procainamide IO/IV 15mg over 30-60 minutes

REF: American Heart Association(AHA),2015