The Basics of the Pediatric Tachycardia for Pediatric Advanced Life Support

The treatment of all patients in distress with significant symptoms begins with the basics, and pediatric tachycardia is no different. Here is the outline of the American Heart Association (AHA) Pediatric Advanced Life Support (PALS) guidelines.

First Steps:

   • 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.  

Identify 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, which might be a 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 0.1 mg/kg rapid bolus (maximum of 6 mg)  This can be repeated with a second dose of 0.2 mg/kg rapid bolus (maximum of 12 mg).
 
If adenosine is unsuccessful, or IV/IO access is not available synchronized cardioversion is indicated. 
   • Start at 0.5-1.0 joules/kg — if not effective increase to 2 joules/kg.
   • Sedate if needed, but do not delay treatment.

Wide Complex Tachycardia (QRS >0.09 secs) — 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 0.1 mg/kg rapid IV bolus maximum of 6 mg.
     - Adenosine 0.2 mg/kg rapid IV bolus maximum of 12 mg.
• If no hypotension, altered level or signs of shock consult an expert (cardiology or electrophysiology) who will consider:
     - Amiodarone 5 mg/kg IV/IO over 20-60 minutes, or
     - Procainamide IO/IV 15 mg over 30-60 minutes.
     - However, these should not be administered together.

The information in this article provided by from the ACLS Training Center is current with respect to 2015 AHA Guidelines for CPR and ECC. These guidelines are current until their expected update in October 2020.

Download a PDF version the pediatric tachycardia algorithm.

Editor's note: The author Judy Haluka, RCIS, EMT, started her career at a tertiary hospital in the cardiac catheterization laboratory following receipt of her bachelor’s in biology/cardiac sciences in the early 1980’s. She is credentialed as a registered cardiovascular invasive specialist through Cardiovascular Credentialing International. She is further credentialed as an emergency medical technician – paramedic through the Pennsylvania Department of Health.