Management of Paediatric SVT - NHSGGC

Management of Paediatric SVT

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1. Key Recommendations for operational use

1 Diagnosis of paediatric supra-ventricular tachycardia (SVT)

SVT in a child usually is a narrow complex tachycardia. It can be difficult to distinguish from sinus tachycardia particularly in infants so consideration of other causes of tachycardia is important. Typical features usually include:

Persistent heart rate >220bpm , can be lower Narrow complex regular tachycardia at a constant rate Patients may or may not present in a clinically shocked state

2 Access Early access is essential and can be gained by siting (ideally) two intra-venous cannulae or using the intra-osseous route early.

3 Management

ABC approach Vagal manoeuvres Adenosine Amiodarone DC Cardioversion

(As detailed on page 4-7)

4 Ongoing care

If clinically stable and cardioverted the patient may be able to remain locally with ongoing joint care with the Scottish Paediatric Cardiac Service. If there are clinical concerns transfer to the Royal Hospital for Children may be required.

5 References See page 7


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2. Document History

Reference Number Version 1.0

Version 1

Writing group

(Chair in bold)

Mark Davidson Paediatric Intensivist ScotSTAR

Rebecca Goldman Consultant Pediatrician Ninewells

Karen McLeod Consultant Cardiologist RHC-Glasgow

Karen Pearson Consultant Anaesthetist Ninewells

Danni Seddon Consultant Anaesthetist RHC-Glasgow

Leanne Daly Retrieval Nurse ScotSTAR

Treasa Magee Retrieval Nurse ScotSTAR

Lauren Williams PICU Pharmacist RHC-Glasgow

Associate Medical Director Andrew Inglis

Date issued XX

Date for review XX

Distribution

BASICS Scotland X

Medic 1 X

Mountain rescue teams X

Referring centres via service websites ✓

Rural GPs Association of Scotland ✓

SAS

Air Ambulance for information

Specialist Services Desk for information

ScotSTAR

EMRS (West) ✓

EMRS (North) ✓

Paediatric ✓

Neonatal ✓


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Tayside Trauma Team for information

3. Scope and purpose

• Overall objectives:

The aim of this guideline is to provide consistent guidance on the assessment and management of paediatric supra-

ventricular tachycardia (SVT).

The most common cause of paediatric tachyarrhythmia is a supra-ventricular tachycardia (SVT). These are common in

infancy and childhood with an incidence of between 1:250 and 1:1000. Most cases are due to re-entrant pathways and

occur in otherwise normal children. They can be very well tolerated for several hours meaning some children may not

present until hemodynamic compromise is evident. They can also present in patients with underlying congenital cardiac

conditions, cardiac conduction disorders or cardiac failure which may be secondary to the tachyarrhythmia. One should

remember to consider other causes of tachycardia including metabolic and electrolyte disturbance, sepsis, trauma and

poisoning.

• Statement of intent:

This guideline is not intended to be construed or to serve as a standard of care. Adherence to guideline recommendations

will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care

or excluding other acceptable methods of care aimed at the same results. The ultimate judgement must be made by the

appropriate healthcare professional(s) responsible for clinical decisions regarding a particular clinical procedure or

treatment plan. Clinicians using this guideline should work within their skill sets and usual scope of practice.

• Feedback:

Comments on this guideline can be sent to: [email protected]

• Equality Impact Assessment:

Applied to the ScotSTAR Clinical Standards group processes.

• Guideline process endorsed by the Scottish Trauma Network Prehospital, Transfer and Retrieval group,

as well as the Scottish Paediatric Cardiac Service Guidelines Group.


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4. Diagnosis & Management of Paediatric SVT

4.1 Diagnosis of SVT Authors’

recommendation Level

[Reference]

This pathway is relevant to patients with broad or narrow complex tachycardia with input from a paediatric cardiology specialist. SVT in a child is usually but not always a narrow complex tachycardia. It can be difficult to distinguish from sinus tachycardia particularly in infants so consideration of other causes of tachycardia is important.

Typical features usually include: o Persistent heart rate >220bpm (can be lower) o Narrow complex regular tachycardia at a constant rate o If seen there are p waves after every QRS complex, at the onset of the T wave

Clinical assessment may show: o No signs of shock:

Poor feeding Dyspnoea, pallor, palpitations, tachypnea, chest discomfort

o Signs of cardiogenic shock: Low BP & prolonged capillary refill Hepatomegaly Agitation or confusion (though conscious state in infants and children

may be normal) 12 lead ECG assessment:

o Narrow complex tachycardia o P waves often difficult to see, if seen usually at onset of T wave

Strong 1-3

4.2 Access Authors’


[Reference]

IV access is the preferred route for administration of drugs in these patients. If the patient is haemodynamically compromised, IO access is appropriate. In patients in whom peripheral IV access is difficult then sedation to obtain either peripheral or central access may be required. Ultrasound guided IV access may be useful in this instance, together with topical local anaesthesia. Sedation guidelines with doses may be found at on the GGC paediatric anaesthetic guideline website, choice of agent or agents will be guided by local familiarity with the drugs. Further advice can be found at: https://www.clinicalguidelines.scot.nhs.uk/nhsggc-paediatric-clinical-guidelines/nhsggc-guidelines/anaesthetics/premedication-guideline-for-paediatric-patients-prior-to-general-anaesthesia/

Strong 2-3


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4.3 Management of SVT Authors’


[Reference]

ABC approach o Airway – ensure clear and patent o Breathing – give oxygen >10L/min o Assess circulation – if shocked call for senior assistance, including anaesthetic

support and prepare for urgent DC cardioversion Patients with known SVT may have their own agreed and tailored SVT pathway to guide

treatment

Strong 1


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Vagal manoeuvres (only if not clinically shocked) o Neonates & infants (ie < 1 year old) – facial immersion in iced water

Ensure monitoring (ECG, SpO2 & BP) in place on patient Explain to family Wrap patient and their arms in towel Immerse whole face in iced water for 5 seconds – do not need to

occlude airway – this will work in 90% cases o Toddlers

Apply facecloth soaked in ice cold water to face for 30 seconds Eyeball pressure is not recommended

o School aged children Valsalva technique

blow hard for 15 seconds on “thumb in mouth” after full inspiration or

blow as hard as possible through a syringe from the plunger end (with the plunger out obviously), if need be asking them to raise a suspended tissue as high as possible with the air jet.

Headstand Child can be helped, with appropriate adult support, to

perform a headstand

Strong 1

Adenosine o Administer preferably via large cannula in proximal vein with 3-way tap

attached o Ensure ECG attached and recording running o Remember adenosine can cause hypotension, chest tightness, flushing and can

cause bronchospasm, though is not contra-indicated in wheeze or asthma o Standard Adenosine vials are a solution of 6mg/2ml – do not reconstitute o Adenosine 150micrograms/kg (max 12mg) by fast injection followed rapidly

with 10ml flush of 0.9% NaCl (Sodium Chloride) o Wait 2 mins – if no return to sinus rhythm then give a second dose of

adenosine 300micrograms/kg (max 12mg) by fast injection followed rapidly with 10ml flush of 0.9% NaCl (Sodium Chloride)

o If there is no response at this stage contact ScotSTAR Pediatric Retrieval team who will dial in the Paediatric Cardiologist & Duty Cardiac Intensivist at the Royal Hospital for Children, Glasgow for further advice - further options include:

3rd dose of adenosine (400-500micrograms/kg (max 12mg)) IV amiodarone (see below) DC cardioversion (see below)

Strong 1-3


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Amiodarone o Make up Amiodarone infusion as follows:

Concentration must be 100mg/50ml (2mg/ml) This concentration is safe to run via a peripheral or central line Calculate rates of infusion as per equations below (round rate to one

decimal place) 50mg/ml Ampoule already in solution – no reconstitution required Draw up required volume for concentration and add to glucose 5%

(volume of glucose = 50ml – volume drawn up from ampoule) Glucose 5% must be used (incompatible with saline) Standard dose delivery is as follows:

Loading dose 25micrograms/kg/min for 4 hours followed by a maintenance infusion of 15micrograms/kg/min as noted below.

Amiodarone loading dose infusion rate in ml/hr = (1.5 x patient weight in kg) / 2

Amiodarone maintenance infusion rate in ml/hr = 0.9 x patient weight (kg) / 2

o Example calculations: for a 5kg patient:

Loading dose infusion rate = (1.5 x 5)/2 = 3.8ml/hr Maintenance infusion rate = (0.9 x 5)/2 = 2.3ml/hr

for a 10kg patient Loading dose infusion rate = (1.5 x 10)/2 = 7.5ml/hr Maintenance infusion rate = (0.9 x 10)/2 = 4.5ml/hr

o Ideally amiodarone should be given via a dedicated point of access for this drug

alone. o Once amiodarone loading dose is completed a further dose of adenosine may

be given to return to sinus rhythm

Strong 2-3

DC cardioversion o If resistant to therapies noted above or if clinically shocked then DC

cardioversion may be required o Sedation is required for DC cardioversion unless the patient is unconscious

If sedation has been used to obtain intravenous (iv) access then this may be supplemented as required.

Sedative agents should be considered in terms of haemodynamic stability, and are at the discretion of the local anaesthetic team and advice from the ScotSTAR team who may advise 1-2mg/kg ketamine to be appropriate depending on the clinical condition of the patient and sedation already used. Patients may be haemodynamically unstable at the time of intubation and clear allocation of roles to plan for all eventualities, including the need for CPR, is recommended. Early intubation prior to further deterioration is encouraged.

Intubation – Ketamine 2mg/kg & Rocuronium 1mg/kg as per ScotSTAR intubation SOP

Maintenance of tube tolerance – Morphine 30micrograms/kg/min & Midazolam 0.05 mg/kg/min or if >5years old Propofol infusions

o Synchronised DC shock 1 J/kg If clinical deterioration into Polymorphic VT or VF then unsynchronised

shock as per APLS pathway

Strong 1-3


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4.3 Ongoing care for paediatric patients with an episode of SVT Authors’


[Reference]

If the patient is not being transferred their ongoing care needs and follow-up should be coordinated with the Duty Consultant Paediatric Cardiologist who can liaise with colleagues to coordinate local or tertiary follow-up.

Conditional N/A

5. References

1. https://www.jpeds.com/action/showPdf?pii=S0022-3476%2816%2931185-4

2. https://www.resus.org.uk/sites/default/files/2021-05/Paediatric%20Cardiac%20Arrhythmias%20Algorithm%202021.pdf

3. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines

Management of Paediatric SVT - NHSGGC

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