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Cardiac Rhythms/ECG Module

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TopicCardiology & the ECG
AuthorAnna McCorquodale
Duration1-2 hours
Facilitator LevelST4+ level used to seeing children acutely
Learner levelAnyone involved in initial assessment of children with cardiac symptoms; paediatric trainees, emergency trainees, foundation doctors
  • Basics (15 mins) with sharing of any departmental guidelines that exist
  • Main session: (2 x 15 minute) case discussions covering key take home messages
  • Advanced session: (2 x 30 minutes) grey case discussions, thoughts around follow up/review timelines, decisions around transfer, how to manage children with a complicated cardiac history
  • Summary (5 mins)

The list of links should be sent out in advance to allow time for people to access the resources at a convenient time:

https://www.gosh.nhs.uk/conditions-and-treatments/conditions-we-treat/supraventricular-tachycardia

Patient information and includes a downloadable leaflet

https://dontforgetthebubbles.com/donovan-dwyer-svt-in-infants-at-dftb17/

Lecture around treating SVT in children and what happens when it doesn’t work (25 mins)

https://apls.org.au/sites/default/files/uploadedfiles/Algorithms%20-%20SVT.pdf

Standard ALSG guideline for UK management of SVT

https://www.escardio.org/static-file/Escardio/Guidelines/publications/NEONATguidelines-neonatal-
slides.pdf

European guidelines on interpretation of neonatal ECGs

https://www.ajemjournal.com/article/S0735-6757(08)00240-4/pdf interpreting the paediatric ECG

Including age related changes

US lecture on children’s arrhythmias. Prioritise listening to the first 30 minutes which given a good overview of aetiology and treatment (53 mins)

Basics of cardiac rhythm problems in the ED

Palpitations are a common reason for children to present to the emergency department, the majority of these will be benign from a cardiac perspective and instead related to stress or anxiety. Appropriate management at the front door will reduce unnecessary investigations in those who can be reasonably reassured but ensure adequate investigation and/or onward referral in those where an underlying cardiac issue is more likely. Palpitations (or descriptions thereof) are common but true arrhythmias are not. Add into this that the majority of children will be in normal sinus rhythm (NSR) by the time of assessment so to truly identify those who have something wrong we have to be confident in identifying arrhythmias where they are present and critical when analysing an ECG in NSR.

An approach to possible cardiac rhythm presentations:

  1. Initial triage/ABC assessment
  2. Immediate arrhythmia management where this is required
  3. Thorough history: how long, how sudden, how often, how is it triggered?
  4. Background medical history. This becomes of pivotal importance where there is a personal cardiac history and in some cases it can be quite historic. Consider a teenager who had heart surgery as an infant, not all rhythm complications occur immediately. In some specific congenital heart diseases, the prevalence of arrhythmias is now being seen as a late surgical complication as children now survive into adulthood.
  5. Family history. A cardiac family history should of course be sought, but think a little outside the box as well. The majority of the inherited rhythm disorders are autosomal dominant but their diagnosis relies on an electrically active heart. Some families have unexplained deaths during sporting events, an unusual number of car accidents, seizures in someone without a formal diagnosis of epilepsy. Where there are a number of unexplained deaths, start to be more critical about what this could mean.

A full examination is necessary but can be completely normal following the event.

If we look at some London-based data: Palpitations – A cause for concern? Stredder et al, Archives of Disease in Childhood 2016 we see that 58% were not asked about triggers, 30% were not asked about duration and, importantly for risk stratification, 59% were not asked for a family history of cardiac disease. All were examined and 98% had an ECG. Are we focused on the immediate presentation and therefore not using all the possible information to hone in on the possibilities?

A 5 year old girl presents feeling ‘butterflies’. She has recently started school, her mother initially thought it was related, however, she has now mentioned this around once a fortnight and not necessarily on school days. Today she complained of the same feeling and mum thought she looked pale so brought her to the ED for an opinion. In triage her heart rate (HR) was 220 so she was taken to resus. Blood pressure (BP) is normal although she does look pale. She is talking to you about butterflies and points to her sternal notch.

This is her 3 lead ECG:

What are your immediate management steps?

Assuming a progression to pharmaceutical therapy is required, what do you do and what do you do if the first attempt does not work?

She cardioverted (phew!), what now? Discharge, if not now, then how do you plan towards this?

What are your immediate management steps?

Assuming a progression to pharmaceutical therapy is required, what do you do and what do you do if the first attempt does not work?

She cardioverted (phew!), what now? Discharge, if not now, then how do you plan towards this?

A 2 month old (ex 34/40) boy presents with an episode at home of perioral cyanosis, with a possible 5 second lapse in breathing and vacant staring. The episode was reported to last around a minute. On arrival at hospital the child was well with normal observations.

Here is his ECG:

How do you classify a BRUE?

What are the important investigations?

What pertinent parts of the ECG would you focus on and what are you trying to rule out?

How do you classify a BRUE?

What are the important investigations?

What pertinent parts of the ECG would you focus on and what are you trying to rule out?

A 12 year old girl was heard to be coughing in the middle of the night. Her mother went in to check and found her daughter coughing and distressed. A few seconds later she fell forwards into her mother’s arms and became lifeless. Mum (first aid trained) gave back blows and started CPR. Paramedics attended within 7 min, this was her 3-lead ECG:

Following a single DC shock she reverted into sinus rhythm at home and was brought to hospital.

What are your initial actions on her arrival?

Are there any specific conditions that might be implicated?

How might these present in a less catastrophic way to the ED?

What do you anticipate the ongoing plans to be for this patient and the family as a whole?

What are your initial actions on her arrival?

Are there any specific conditions that might be implicated?

How might these present in a less catastrophic way to the ED?

What do you anticipate the ongoing plans to be for this patient and the family as a whole?

A 16 year old boy with a completed Fontan circulation for a congenital diagnosis of hypoplastic left heart syndrome. He is complaining of intermittent butterflies in his tummy. Mum has brought him to the ED as she has been unable to contact his specialist team and he was feeling dizzy whilst walking. There is no history of arrhythmias since discharge from hospital. You do not have access to his inpatient notes from the time of repair as this was done over a decade ago.

He is haemodynamically stable at triage.

What rhythm possibilities does this case suggest?

What are the medical priorities for this child?

What rhythm possibilities does this case suggest?

What are the medical priorities for this child?

Question 1

Answer 1

Question 2

Answer 2

Question 3

Answer 3


Please download our Facilitator and Learner guides

Author

  • Anna McCorquodale is a general paediatrics registrar working in the Royal London Emergency Dept. She loves the acute take, neonates, ECGs, mentoring and teaching. When not at work she is either running after her own two girls, training for a triathlon, or both.

    View all posts

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