This issue includes 4 hours of ACEP/AMA category 1 CME credit.

Authors: Anna Karpas, MD
Peer Reviewers: Christine M. Walsh-Kelly, MD, Ghazala Q. Sharieff, MD, FACEP, and Alfred Sacchetti, MD, FACEP
Publication date: July 14, 2006

Excerpt from the issue…
The parents of a 14-month-old female bring her to your ED during a busy evening shift. The triage nurse documents that the patient is pale and fussy.

The child was seen at a local urgent care clinic yesterday. She was diagnosed with an ear infection and started on oral antibiotics. Now, her parents’ biggest concern is that she has been getting “sicker” during the day and she also seems more tired and uncomfortable. She refuses to eat and has had fewer wet diapers than normal. There is no history of vomiting or diarrhea.

Vital signs on the chart: T 38 C, P 210, R 52, BP 92/62, Pox 99% RA. During your examination, you note a well-nourished girl with bilateral acute otitis media. She is pale and tired-appearing. You count her heart rate at 210 BPM, and her pulse is rapid and weak. On the cardiopulmonary monitor, you can see a narrow rhythm.

But why is the heart rate so fast? Fever? Her temperature is slightly elevated …dehydration? shock? …pain or earache – related? What am I missing?

Over the next several minutes an IV is started, blood culture and basic labs sent, a normal saline bolus started, a dose of rectal Acetaminophen given and Auralgan drops placed in both ears, yether HR remains at 210 BPM. You tell yourself that this rate is too high for a sinus tachycardia, and order a 12-lead EKG, the result of which confirms your suspicion that the patient has a supraventricular tachycardia (SVT).

Now, new questions come to mind. Should I try vagal stimulation? Does it really work for infants with SVT? You order a dose of Adenosine, and realize that the patient’s nurse just started working in the ED and may not be familiar with the unique way of giving Adenosine.

What if one dose does not work?…is the patient stable enough, or should I prepare for cardioversion? …should I call an on-call cardiologist now? …will I need to sedate the child for the cardioversion? …could it still be a sinus tachycardia?…

Tachycardia is a common problem that ED physicians face on a daily basis. Generally it is a benign condition related to emotional distress, especially in a young child, febrile illnesses, dehydration of variable degrees, or pain. Primary pediatric tachyarrhythmias are relatively infrequent, and in a healthy child, the majority are of a benign nature. It is the small number of potentially dangerous tachyarrhythmias, occasionally masked by another illness, that should be rapidly identified and appropriately managed by the ED physician. In this issue of Pediatric Emergency Medicine PRACTICE, we will review an evidence-based approach to the evaluation and management of children with tachyarrhythmias.

CME Objectives
Upon completing this article you should be able to:
1. Quickly recognize or suspect the presence of cardiac tachyarrhythmia
2. Be able to differenciate between sinus tachycardia, supraventricular tachycardia and other types of tachyarrhythmias
3. Describe the use of diagnostic tests in the evaluation of patients with suspected tachyarrhythmias
4. Be familar with the medications and other treatments available for the management of various tachyarrhythmias

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