Cardiac emergencies are not uncommon in pediatric patients. Primary cardiac emergencies, defined as originating from the cardiovascular system, are somewhat less common; most conditions that affect heart function have their origins elsewhere in the body. In most cases, management principles are intended to address the underlying problem.
Prepare, in advance, any calculations that may be necessary to provide care for pediatric patients. A Broselow tape, the BCEHS Handbook, and many other tools are available that can simplify this process.
Recognize that in the majority of cases, respiratory failure is the primary cause of cardiac dysfunction. Focus on adequate oxygenation and ventilation.
Be aware that these are some of the most stressful types of out-of-hospital events. Pre-arrival planning, and effective crew resource management, are essential for ensuring an organized approach.
High quality CPR, appropriate ventilation, timely vascular access, and a moderate scene time are proven elements that improve survival from cardiac arrest with good outcomes.
Even transient, apparently resolved events require assessment in-hospital as they may be a sign of an underlying condition.
Resuscitation and cardiac emergencies for neonates (< 28 days of age) differ in approach than that for older patients. See CPG M11 and CPG M13 for additional information.
Sinus arrhythmia is a normal variant seen in children and is described as a variation in heart rate over time without symptoms. The variation coincides with breathing. Typically, the rate increases during inhalation and decreases during exhalation. There is no concern if this is the lone finding.
Tachycardia is a sustained increased heart rate. A heart rate > 180 bpm in a child, or > 220 bpm in an infant, is unlikely to be rapid sinus tachycardia and more likely to be an arrhythmia.
Narrow complex tachycardia (QRS < 0.09 seconds) with visible p-waves is considered to be sinus tachycardia and a primary cause should be determined. No specific cardiac management of sinus tachycardia is needed. Treat the underlying cause (e.g., pain, fever, hypovolemia, hypoxia, or anemia) as appropriate.
Narrow complex tachycardia with no visible p-waves, with abrupt onset or termination and no change with activity, is considered to be SVT. Stable patients with no previous history and no hemodynamic compromise require support with oxygen, continuous cardiac monitoring, and conveyance to ED, with equipment for electrical cardioversion immediately available. Symptomatic patients should be treated with a vagal maneuver, adenosine, or cardioversion if unstable.
Wide complex tachycardia (QRS > 0.08 seconds) in a conscious patient with adequate perfusion and a heart rate > 150 bpm is probably in stable ventricular tachycardia and requires support with oxygen, continuous cardiac monitoring, and conveyance to ED, with equipment for electrical cardioversion immediately available.
Wide complex unstable tachycardia in a child with poor perfusion should be considered ventricular tachycardia and be treated rapidly with synchronized cardioversion with sedation if readily available.
In refractory cases or situations where appropriate treatment options are unclear, contact Clinicall.
Bradycardia is a sustained decreased heart rate. In the pediatric populations, bradycardia is usually secondary to a different pathology and treatment focuses on the underlying cause.
As hypoxia may be a contributor, ensure optimized oxygenation and ventilation, including bag-valve mask if needed.
Consider a 20cc/kg crystalloid bolus to address hypotension.
In a pediatric patient with a HR < 60 bpm coupled with poor perfusion, CPR is indicated. Ensure maximal oxygenation and bag-valve mask ventilation is provided. If heart rate remains < 60 bpm for 30 seconds of effective oxygenation and ventilation, begin chest compressions. Signs of poor perfusion include cyanosis, mottling, decreased LOC, and lethargy.
Epinephrine 0.01 mg/kg IV/IO is indicated for bradycardia unresolved by oxygenation, ventilation, and chest compressions.
Atropine is only indicated when increased vagal tone or primary AV block is the suspected etiology of the bradycardia; with all other causes, epinephrine is preferred.
Bradycardia with complete heart block or a history of congenital or acquired heart disease, pacing may be indicated.
BRUE (Brief Resolved Unexplained Event) and ALTE (Apparent Life Threatening Event) are not specific disorders but terms for a group of alarming symptoms that can occur in infants. They involve the sudden appearance of respiratory symptoms (such as apnea), change in colour or muscle tone, and/or altered responsiveness. Events typically occur in children < 1 year with peak incidence at 10 to 12 weeks. Some of these events are unexplained (and designated BRUEs), but others result from numerous possible causes including digestive, neurologic, respiratory, infectious, cardiac, metabolic, or traumatic (e.g., resulting from abuse) disorders.
First Responder (FR) Interventions
Keep the patient at rest
Position the patient: if symptoms suggest hypotension, position supine