Disorder of Rhythm in Childreen

7/31/2019 Disorder of Rhythm in Childreen

1/41

Disorder of Rhythm in

Childreen

By : Amy Fareena

Mardiana KamalGroup 93


2/41

Normal Resting Heart Rate

(in beats per minute)

Newborn : 140-160

1 year : 120

5 years : 10010 years : 80-85

15 years : 70-80


3/41

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


4/41

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.


5/41

The Q-T interval represents the time for electrical activation and

inactivation of the ventricles


6/41

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


7/41

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.


8/41

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


9/41

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


10/41

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


11/41

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


12/41

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


13/41

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


14/41

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


15/41

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)


16/41

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


17/41

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


18/41

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)


19/41

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


20/41

Treatment

Antiarrhythmic agents Adenosine,

Procainamide, Digoxin, Propanolol,

Amiodarone, Lidocaine

goals of pharmacotherapy are to

reduce morbidity and prevent

complications


21/41

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.


22/41

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.


23/41

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


24/41

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


25/41

Signs & Symptoms

Pounding heartShortness of breath

Chest pain

Rapid breathing

Dizziness

Loss of consciousness (in serious

cases)

Numbness of various body parts


26/41

Diagnosis

ECG beat can be count and most have narrowQRS complex


27/41

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


28/41

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.


29/41

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.


30/41

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


31/41


32/41

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


33/41

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


34/41

Characteristic delta wave


35/41

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


36/41

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)


37/41

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


38/41

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,


39/41

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


40/41

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


41/41

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.jsp

Documents

Disorder of Rhythm in Childreen