Pediatric Tachycardia With a Pulse and Poor Perfusion Algorithm

This figure conveys the Pediatric Tachycardia With a Pulse and Poor Perfusion Algorithm. It includes a flowchart on the left and a table of related information to the bottom right. The flowchart consists of numbered boxes and hexagons linked together with arrows. It originates at the top with box number 1. This green box is titled, “Identify and treat underlying cause.” It is followed by five points:
  • Maintain patent airway; assist breathing as necessary.
  • Oxygen.
  • Cardiac monitor to identify rhythm; monitor blood pressure and oximetry.
  • I.O. or I.V. access.
  • 12-Lead ECG if available; don’t delay therapy.
From here, an arrow points downward to item 2. This red hexagon says, “Evaluate QRS duration.” From here, the pathway branches. If the evaluation determines the QRS is narrow (duration less than or equal to 0.09 seconds), an arrow leads down and to the right to item 3, which is another red hexagon. It says, “Evaluate rhythm with 12-lead ECG or monitor.” Once again, the pathway branches. One path leads down to box 4. This orange box is titled “Probable sinus tachycardia,” and it includes 5 points:
  • Compatible history consistent with known cause.
  • P waves present or normal.
  • Variable R-R; constant PR.
  • Infants: rate usually less than 220 per minute.
  • Children: rate usually less than 180 per minute.
From box 4, an arrow points down to box 6. This green box says, “Search for and treat cause.” This pathway ends here. Going back up to hexagon 3, which says “Evaluate rhythm with 12-lead ECG or monitor,” the other pathway leads to box 5. This orange box is titled “Probable supraventricular tachycardia.” It includes 5 points:
  • Compatible history (vague, nonspecific); history of abrupt rate changes.
  • P waves absent or abnormal.
  • Heart rate not variable.
  • Infants: rate usually greater than or equal to 220 per minute.
  • Children: rate usually greater than or equal to 180 per minute.
An arrow points from box 5 to box 8. But along the pathway, standalone box 7 points to the connecting line. Box 7, which is green, says, “Consider vagal maneuvers (No delays).” Box 8, which is also green says, “If I.O. or I.V. access present, give adenosine; or if I.O. or I.V. access is not available, or if adenosine is ineffective, synchronized cardioversion.” This pathway ends here. Going back up to red hexagon 2, which says “Evaluate QRS duration,” we already explored the pathways for a narrow QRS. If the QRS is wide (duration greater than 0.9 seconds), an arrow points down and to the right to box 9. This orange box says, “Possible ventricular tachycardia.” It then points to item 10, which is a red hexagon that asks, “Cardiopulmonary compromise?” It includes three points:
  • Hypotension.
  • Acutely altered mental status.
  • Signs of shock.
From here, the pathway branches. If the answer is “Yes,” an arrow leads down to box 11. This green box says, “Synchronized cardioversion.” If the answer is “No,” an arrow leads to box 12. This green box says, “Consider adenosine if rhythm is regular and QRS is monomorphic.” Box 12 points to green box 13. It says, “Expert consultation advised,” followed by two points:
  • Amiodarone.
  • Procainamide.
The one-column table at the bottom right is titled “Doses or Details.” It includes two sections. The first is “Synchronized Cardioversion.” Its related text says, “Begin with 0.5 to 1 Joule per kilogram; if not effective, increase to 2 Joules per kilogram. Sedate if needed, but don’t delay cardioversion.” The second section is “Drug Therapy.” Its text states: “Adenosine I.O. or I.V. dose: First dose: 0.1 milligram per kilogram rapid bolus (maximum: 6 milligrams). Second dose: 0.2 milligrams per kilogram rapid bolus (maximum second dose: 12 milligrams).” It then states, “Amiodarone I.O. or I.V. dose: 5 milligrams per kilogram over 20 to 60 minutes.” Then it continues, “or Procainamide I.O. or I.V. dose: 15 milligrams per kilogram over 30 to 60 minutes.” The related text concludes by advising, “Do not routinely administer amiodarone and procainamide together.” This figure is copyright 2015 by the American Heart Association.