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7/31/2019 Disorder of Rhythm in Childreen
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Disorder of Rhythm in
Childreen
By : Amy Fareena
Mardiana KamalGroup 93
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Normal Resting Heart Rate
(in beats per minute)
Newborn : 140-160
1 year : 120
5 years : 10010 years : 80-85
15 years : 70-80
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ArrhythmiaCardiac dysrhythmia (also knownas arrhythmia and irregular heartbeat) is group ofconditions in which there is abnormal electrical activity ofthe heartheart beat may be too fast (tachycardia) or too slow(bradycardia), and may be regular or irregular.
Types of arrhythmia is children includes :
-Long Q-T Syndrome (LQTS)
- Premature Atrial Contraction (PAC) and PrematureVentricular Contraction (PVC)
- Tachycardia
-Sinus Tachycardia
-Supraventricular Tachycardia- Wolff-Parkinson-White Syndrome
-Ventricular Tachycardia
-Bradycardia
-Sick Sinus Syndrome
-Complete Heart Block
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Long Q-T Syndrome (LQTS)
Prolong Q-T interval on ECG
infrequent, hereditary disorder. May also
occur in healthy people.
usually affects children or young adults.
Studies of otherwise healthy people with
LQTS indicate that they had at least one
episode of fainting by the age of 10. Themajority also had a family member with a
long Q-T interval.
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The Q-T interval represents the time for electrical activation and
inactivation of the ventricles
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Signs & Symptoms
May be asymptomaticIf have symptoms, child may exhibit
syncope and abnormal heartbeat
Patients may show prolongation of the Q-Tinterval during physical exercise, intense
emotion or when startled by a noise. They
dont necessarily have a prolonged Q-T
interval all the time. DiagnosisMay also result in deaf or may have
congenital deafness
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Diagnosis
LQTS may be suspected if there is history
of sudden death in the family or repeated &
unexplained episodes of fainting.
diagnosis is not easy since 2.5% of thehealthy population have prolonged QT
interval, and 1015% of LQTS patients
have a normal QT interval.
LQTS "diagnostic score" may be used.
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QTc (Defined as QT interval / square root of RR interval)>= 480 msec - 3 points
460-470 msec - 2 points
450 msec and male gender - 1 point
Tordes de Pointes - 2 points
T wave alternans - 1 point
Notched T wave in at least 3 leads - 1 point
Low heart rate for age (children) - 0.5 points
Syncope (one cannot receive points both for syncope andtorsades de pointes)
With stress - 2 pointsWithout stress - 1 point
Congenital deafness - 0.5 points
Family history (the same family member cannot be counted forLQTS and sudden death)
Other family members with definite LQTS - 1 point
Sudden death in immediate family (members before the age 30) - 0.5points
four or more points, the probability is high for LQTS
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Managements
Arrhythmia prevention :- beta blockers
- Na+ channel blockers (Mexiletin)
- potassium supplimentsArrhythmia termination :
- implantable cardioverter-defibrillator
(ICD) on older patients & whenpatients have still experiencedsyncope even with beta blockerstherapy
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Premature Atrial Contraction (PAC) and
Premature Ventricular Contraction (PVC)
Premature beats or extra beats most often cause
irregular heart rhythmsThose that start in atria are called premature atrialcontractions or PAC
Ventricle; Premature ventricular contractions or
PVCPremature beats are very common in normalchildren and teenagers
Premature heart beats may be perceived as askipped heart beat, a strong beat, or a feeling of
suction in the chest. Of course the heart doesntreally skipped a beat, but actually, an extra beatcomes sooner than normal. Then there's usually apause that causes the next beat to be moreforceful
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Usually no cause can be found and no specialtreatment is needed. The premature beats maydisappear later. Even if they continue, the child willstay well and won't need any restrictions.
Occasionally premature beats may be caused bydisease or injury to the heart.
So further test has to be done to make sure thechilds heart is functioning well because TAC cantrigger a more serious arrhythmia such as atrial
flutter or atrial fibrillationOn ECG, PACs are characterized by anabnormally shaped P wave
PVC; S-T is much shorter
Several PVCs in a row becomes a formof ventricular tachycardia (VT), which is adangerous rapid heartbeat. This may also causechest pain, a faint feeling, fatigue, orhyperventilation after exercise symptomatic
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Treatment for symptomatic PVCPVCs must be watched carefully, as theymay cause VT
Pharmacological agents :
- Antiarrhythmics: these agents alter the
electrophysiologic mechanisms responsiblefor PVCs
- Beta blockers
-Calcium channel blockers
Electrolytes replacement :
- Magnesium supplements (e.g.magnesium citrate, orotate, Maalox, etc.)
- Potassium supplements
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Pediatric Tachycardia
In children, the normal heart rate is
age dependent, and the definition of
tachycardia also varies according to
age
Tachycardia can be due to a
physiologic response of the heart to
noncardiac stimuli or to a truedysrhythmia
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Cause
Hyperdynamic cardiac activity :
Increased heart rate and contractility arephysiologic responses to catecholamine
release. Catecholamine release may occur withstress or anxiety, exercise, fever orinfection, pain, anemia, seizure,
hypovolemia, hypoxia, drugs ormedications/stimulants, vasodilation (eg,anaphylaxis), hypoglycemia
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True dysrhythmias :
Supraventricular tachycardia (SVT)
-Drug induced (eg, amphetamines, cocaine, caffeine,ephedrine, antihistamines, phenothiazines, antidepressants,tobacco, albuterol, theophylline, general anesthesia)
-Wolff-Parkinson-White syndrome (WPW)
-Hyperthyroidism
-Congenital heart disease
-Postoperative cardiac repair
-Atrial ectopic tachycardia
Atrial fibrillation or atrial flutterDrug induced
Wolff-Parkinson-White syndrome (WPW)
Postoperative cardiac repair
Congenital or rheumatic mitral disease
Hyperthyroidism
Junctional ectopic tachycardia (JET) - Postoperative cardiacrepair
Ventricular tachycardia (VT)
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Causes of VT includes :
-Drug induced (eg, tricyclics, phenothiazines, antiarrhythmics,chloral hydrate, organophosphates, hydrocarbons, digoxin,amphetamines, cocaine, arsenic)
-Prolonged Q-T syndrome/torsades de pointes
-Myocarditis
-Rheumatic fever
-Mitral valve prolapse
-Cardiomyopathy
-Myocardial ischemia
-Postoperative cardiac repair-Hyperkalemia (peaked T waves, prolonged QRS and QT
intervals)
-Hypocalcemia (increased QT intervals secondary to ST-segment prolongation)
-Hypokalemia (especially in association with digoxin use due toits synergistic effects on automaticity and conduction)
-Hypomagnesemia (associated with hypocalcemia andhypokalemia)
-Cardiac tumors
-Arrhythmogenic right ventricular dysplasia
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Signs&symptoms
Chest pain, Palpitations, Syncope,
Dizziness, Shortness of breath,
Diaphoresis (for infantswhile
feeding), cyanosis, Poor peripheralperfusion, Neurologic changes
(mental status, motor/sensory
deficits), Decrease in intake andoutput, Trauma, Pain, Fever, Cardiac
gallop
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Diagnosis
Laboratory studies for tachycardia mayinclude the following:
- Electrolyte levels - Particularly potassium,bicarbonate, calcium, and magnesium
- Blood glucose level- Complete blood count
- Toxicology screen
- Arterial blood gas measurement
- Thyroid function tests
- Urine catecholamine metabolites(homovanillic and vanillylmandelic acid)
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DDX
Anemia, Chronic
Atrial Fibrillation
Atrial Flutter
Hyperthyroidism, Thyroid Storm, and Graves DiseaseHypoglycemia
Pediatrics, Bacteremia and Sepsis
Pediatrics, Dehydration
Pediatrics, Diabetic Ketoacidosis
Torsade de Pointes
Toxicity, AmphetamineToxicity, Anticholinergic
Toxicity, Antidepressant
Toxicity, Antihistamine
Toxicity, Cocaine
Toxicity, Cyclic Antidepressants
Toxicity, Digitalis
Toxicity, HallucinogenToxicity, Organophosphate and Carbamate
Toxicity, Sympathomimetic
Toxicity, Theophylline
Toxicity, Thyroid Hormone
Ventricular Tachycardia
Wolff-Parkinson-White Syndrome
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Treatment
Antiarrhythmic agents Adenosine,
Procainamide, Digoxin, Propanolol,
Amiodarone, Lidocaine
goals of pharmacotherapy are to
reduce morbidity and prevent
complications
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Supraventricular Tachycardia
The most common abnormal tachycardia inchildren
also called paroxysmal atrial tachycardia (PAT) orparoxysmal supraventricular tachycardia (PSVT)
The fast heart rate involves both atrial & ventricle.This isn't a life-threatening problem for mostchildren and adolescents. Treatment is onlyconsidered if episodes are prolonged or frequent.For many infants, SVT is a time-limited problem.Treatment with medications often stops after six to12 months.
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SVT may occur in very young infants with
otherwise-normal hearts. The heart rate is
usually more than 220 beats a minute.Infants with an SVT episode may breathe
faster than normal and seem fussy or
sleepier than usual. This situation must be
diagnosed and treated to return the heartrate to normal. Once the rhythm is normal,
medication usually can prevent future
episodes.
Sometimes SVT can be detected while ababy is still in the womb. Then the mother
may take medications to slow her baby's
heart rate.
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If an older infant or child has SVT, thechild may be aware of the rapid heartrate. This may be associated with
palpitations, dizziness,lightheadedness, chest discomfort,upset stomach or weakness.
Valsalva maneuver - children canlearn ways to slow down their heartrate using this method.
Older children are more likely to havemore episodes of tachycardia.They're more likely to need prolongedtreatment. They also may need more
diagnostic tests
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cause
Drug induced (eg, amphetamines, cocaine,caffeine, ephedrine, antihistamines,
phenothiazines, antidepressants, tobacco,
albuterol, theophylline, general anesthesia)
Wolff-Parkinson-White syndrome (WPW)
Hyperthyroidism
Congenital heart disease
Postoperative cardiac repairAtrial ectopic tachycardia
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Signs & Symptoms
Pounding heartShortness of breath
Chest pain
Rapid breathing
Dizziness
Loss of consciousness (in serious
cases)
Numbness of various body parts
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Diagnosis
ECG beat can be count and most have narrowQRS complex
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Management
Physical maneuver- activation of the parasympathetic
nervous system by Valsalvamaneuver
- other vagal maneuvers including:holding ones breath for a fewseconds, coughing, plunging the face
into cold water,drinking a glass of icecold water, and standing on one'shead. Also Carotid sinus massage
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Pharmacology
- Adenosine, an ultra short acting AV
nodal blocking agent, is indicated ifvagal maneuvers are not effective.
- If this works, followup therapy
with diltiazem, verapamil or metoprolol may be indicated.
- SVT that does not involve the AV
node may respond to other anti-arrhythmic drugs such
as sotalol or amiodarone.
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Cardioversion
- Also called electrical countershock
- If the patient is unstable or othertreatments have not been effective.
- small catheter (a thin, flexible tube) is
placed through the nostril into theesophagus. A small amount of
electricity is sent through this catheter
giving a small electrical shock to thechest wall. This is effective to stop the
SVT.
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Wolff-Parkinson-White syndrome
congenital abnormality involving thepresence of abnormal conductive tissuebetween the atria and the ventricles inassociation with supraventricular
tachycardia (SVT)involves preexcitation, which occursbecause of conduction of an atrial impulsenot by means of the normal conductionsystem, but via an extra atrioventricular(AV) muscular connection, termed asaccessory pathway (AP), that bypasses the
AV node
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Clinical Presentation
Patients with Wolff-Parkinson-White(WPW) syndrome may present withanything from mild chest discomfort orpalpitations with or without syncope to
severe cardiopulmonary compromise orcardiac arrest
infant may frequently be irritable, may nottolerate feedings, or may demonstrateevidence of congestive heart failure
verbal child with WPW syndrome usuallyreports chest pain, palpitations, orbreathing difficulty
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DiagnosisClassic ECG
short PR (< 120 ms) ,
QRS >120 ms with a slurred onset of the QRS waveform
producing a delta wave in the early part of QRS
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Characteristic delta wave
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Management
Radio frequency ablation (RFA) -ablation of the accessory pathway[AP]
antiarrhythmic drugs slowing APconduction, or
AV blockers to slow AV nodal
conduction ca+ channel blockers(verapamil, diltiazem)
Beta blockers metoprolol, atenolol
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Congenital complete heart block
Third-degree congenital atrioventricular
block (CAVB) is usually a complete heart
block (ventricular impulses slower than and
dissociated from the atrial rhythm) seen ina fetus or at an early age
may be present at or even before birth
2 types
- isolated CAVB (structurally normal heart)
- complex CAVB (congenital heart defects)
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etiology
CAVB with structural heart disease isconsidered to be caused by failure of the
AV conduction system to develop duringheart development. This may be a result of
increased distance between the AV nodeand the ventricular conduction tissues, aswhen associated with structural congenitalheart disease or damage related to the
passage of maternal autoantibodiesBut for isolated CAVB, theres no clearetiology
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Clinical presentationMother may be asymptomatic. But fetus inprenatal period usually presents withbradycardia or hydrops fetalis. Usually thisis found out by accident, or if siblings haveheart block (17% re-occurrence in family
members)Newborns with congenital heart block maypresent with a hydropic appearance, maydevelop signs of low cardiac output orcardiac failure few hours or few days afterbirthIn older childern; pallor, mottling, lethargy,exercise intolerance, palpitations,dizziness, or syncope,
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Diagnosis
ECG long QT
Children more than 7yrs old may be
tested using stress test
Chest radiography can reveal
cardiomegaly and pleural effusions
may also be identified during prenatal
examinations, in the perinatal period,
or during childhood or adulthood
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Management
Medications arent nessecary for children with thisdz
Currently, medical care for children with completeheart block is focused on the optimal timing toplace a pacemaker.
Pacemaker is to ensure positive outcome and toensure the child could live normaly because inserious cases (eg when syncope is present),sudden death may occur
In emergency cases, chronotropic medications,with or without inotropic agents, may be helpful infetuses and newborns with hydrops fetalis,congestive heart failure, or low cardiac output
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References
http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Types-of-Arrhythmia-in-Children_UCM_302023_Article.jsp#.TslBppWP_QB
http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/AF-and-Children_UCM_423774_Article.jsp#.TskOzpWP_QA
http://en.wikipedia.org/wiki/Cardiac_dysrhythmia
http://en.wikipedia.org/wiki/Premature_atrial_contraction
http://en.wikipedia.org/wiki/Premature_ventricular_contraction
http://en.wikipedia.org/wiki/Long_QT_syndrome
http://www.emedicinehealth.com/heart_rhythm_disorders/article_em.htm
http://www.nlm.nih.gov/medlineplus/ency/article/003399.htm
http://pediatrics.aappublications.org/content/96/1/122
http://pediatrics.aappublications.org/content/26/3/402.short
http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Types-of-Arrhythmia-in-Children_UCM_302023_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Types-of-Arrhythmia-in-Children_UCM_302023_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/AF-and-Children_UCM_423774_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/AF-and-Children_UCM_423774_Article.jsphttp://en.wikipedia.org/wiki/Cardiac_dysrhythmiahttp://en.wikipedia.org/wiki/Premature_atrial_contractionhttp://en.wikipedia.org/wiki/Premature_ventricular_contractionhttp://en.wikipedia.org/wiki/Long_QT_syndromehttp://www.emedicinehealth.com/heart_rhythm_disorders/article_em.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003399.htmhttp://pediatrics.aappublications.org/content/96/1/122http://pediatrics.aappublications.org/content/26/3/402.shorthttp://pediatrics.aappublications.org/content/26/3/402.shorthttp://pediatrics.aappublications.org/content/96/1/122http://www.nlm.nih.gov/medlineplus/ency/article/003399.htmhttp://www.emedicinehealth.com/heart_rhythm_disorders/article_em.htmhttp://en.wikipedia.org/wiki/Long_QT_syndromehttp://en.wikipedia.org/wiki/Premature_ventricular_contractionhttp://en.wikipedia.org/wiki/Premature_atrial_contractionhttp://en.wikipedia.org/wiki/Cardiac_dysrhythmiahttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/AF-and-Children_UCM_423774_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/AF-and-Children_UCM_423774_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/AF-and-Children_UCM_423774_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/AF-and-Children_UCM_423774_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/AF-and-Children_UCM_423774_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Types-of-Arrhythmia-in-Children_UCM_302023_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Types-of-Arrhythmia-in-Children_UCM_302023_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Types-of-Arrhythmia-in-Children_UCM_302023_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Types-of-Arrhythmia-in-Children_UCM_302023_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Types-of-Arrhythmia-in-Children_UCM_302023_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Types-of-Arrhythmia-in-Children_UCM_302023_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Types-of-Arrhythmia-in-Children_UCM_302023_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Types-of-Arrhythmia-in-Children_UCM_302023_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Types-of-Arrhythmia-in-Children_UCM_302023_Article.jspRecommended