Treatment:
All patients presenting to the ED with tachyarrhythmias should have an immediate hemodynamic assessment, a 12-lead ECG, and continuous cardiac monitoring initiated. The initial treatment strategy depends on the patient’s presentation and clinical status (hemodynamically stable or unstable).
SVT, Hemodynamically Unstable:
Altered mental status or signs of shock and severe heart failure may be present. Perform immediate synchronized cardioversion with 0.5 to 1 J/kg. Cardioversion in a synchronous mode will not allow a shock to be delivered during a vulnerable repolarization period. Perform cardioversion in children over 10 kg using adult electrode paddles, which results in lower thransthoracic impedance and higher current flow. If time permits, give the patient adequate sedation before the procedure. Sedation for cardioversion may be provided by 0.1 mg/kg midazolam and/or 1 to 2 mg/kgpropofolintravenous.
Ventricular Tachycardia: Hemodynamically Unstable:
Acute management of ventricular tachycardia requires a full evaluation of the ABCs of resuscitation. Management of VT with a pulse in an unstable patient requires immediate synchronized cardioversion at 0.5 to 1 J/kg. Medications may include amiodarone, lidocaine, or procainamide. Amiodarone and procainamide should not be used together. Treat pulseless VT or VF with defibrillation at 2 J/kg and re-start CPR immediately after defibrillation. If the defibrillation is unsuccessful, epinephrine should be given, and repeated every three to five minutes as necessary. If shockable rhythm is present after five rounds of CPR, additional defibrillation attempts with 4 J/kg are indicated (PALS 2005). Seek and treat any acute and reversible causes, such as electrolyte abnormalities, acidosis, or drug toxicity. Intravenous administration of magnesium sulfate (MgSo4) was found to be a very effective and safe treatment for torsades de pointes in pediatric patients with LQTS.67 Bolus injection is given at 3 to 9 mg/kg initially up to 12 mg/kg over one to two minutes until the torsades de pointes is completely abolished. A second bolus can be given under the same protocol within 5 to 15 minutes. It should be followed by a continuous infusion at a rate of 0.5 to 1.0 mg/kg/hr. When the total bolus dose of MgSo4 exceeds 24 mg/kg in a pediatric patient and 400 mg in adults, measurement of serum Mg concentration and careful monitoring is mandatory. Optimal serum Mg concentration is 3 to 5 mg/dL.
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