Pediatric emergency medicine trisk 1722 1722
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Patients with either bradycardia or tachycardia may present with signs of
decreased cardiac output including fatigue, dizziness, syncope, and sudden death.
Presentation depends on the rate of the rhythm, the patient’s age, how long the
patient has been in the abnormal rhythm, and co-existing conditions such as
structural heart disease.
Infants with dysrhythmias may present with increased crying, poor color,
decreased responsiveness, poor feeding, vomiting, wheezing, or tachypnea.
Abnormal heart rates may be picked up on routine well child visit and
subsequently referred to the ED. There may be a history of tachycardia in utero or
earlier in life.
Older children and adolescents with tachycardia often state their heart is
“beeping” fast. In addition, they endorse dizziness, palpitations, fatigue, or
sudden onset/offset of symptoms. Stomach pain, combativeness, or vomiting may
be signs of poor cardiac output due to dysrhythmias. Some patients with incessant
tachycardia may be asymptomatic and have the abnormality discovered
incidentally.
Rarely do older children or adolescents with bradycardia endorse the feeling of
the heart beating too slowly. Rather, they present with irritability, pallor,
combativeness, fatigue, or syncope.
Triage. Any patient presenting with a heart rate that is out of the normal range for
age and clinical situation should have full vital signs and perfusion checked. The
emergency physician should evaluate any symptomatic patient giving special
consideration to patients with a cardiac history, pacemaker or implantable
cardioverter–defibrillator (ICD), syncope, or history of arrhythmias.
Initial Assessment/H&P. The history should focus on the presence of red flags
including previous tachycardia, current medications and adherence to medical
therapy, prior response to adenosine, length of symptoms, prior heart
operation/catheterization/EP procedure, or presence of a pacemaker or ICD.
Tachycardia in patients with underlying cardiac dysfunction should raise concern,
even if the patient looks well. Infants, patients with heart transplant, single
ventricle or palliated heart disease, and adults with CHD should also raise the
provider’s index of concern. The focus of the initial examination is to assess the
hemodynamic status using heart rate, perfusion, level of consciousness,
tachypnea, and hepatomegaly or other signs of CHF. Reviewing prior baseline
and tachycardia EKGs aids in analyzing the presenting arrhythmia. Often
treatment that was effective in prior episodes will be effective again; so if time
allows, obtain this information from the medical record or the family.
