Pediatric tachycardia algorithm

Last updated: June 27, 2023

When a child presents with tachycardia with pulses but poor perfusion, assess and support ABCs as needed, give oxygen, and attach the monitor/defibrillator as soon as possible.

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Evaluate the rhythm with a monitor or 12-lead ECG. If the QRS is narrow (≤ 0.08 sec) treat it as probable sinus tachycardia. Sinus tachycardia has a gradual onset and may be determined by history. The p waves are present and have a normal presentation. The R to R interval may be variable and have a constant P to R interval. Infant rates will usually be under 220 beats per minute and children under 180 beats per minute. Sinus tachycardia should be treated by searching for the underlying cause and treating it accordingly.

Supraventricular tachycardia (SVT) is a heart rate of ≥ 220 for infants and ≥ 180 for children. SVT tends to have a sudden onset with a vague or nonspecific history. The P wave is absent or abnormal and the R to R interval is not variable. To treat, consider a vagal maneuver if it doesn’t delay accessing for IV or cardioversion. Place an IV and give adenosine 0.1 mg/kg (with a max of 6 mg) by rapid bolus. This may be repeated with 0.2 mg/kg IV bolus (with a max of 12 mg). If an IV is not readily available, consider synchronized cardioversion at 0.5 to 1 J/kg, this can be increased to 2 J/kg if the first dose is not effective. Consider sedation for cardioversion as long as it does not cause a delay.

If the tachycardia has a wide QRS (>0.08 seconds) and the child has a pulse, treat for ventricular tachycardia. Prepare for synchronized cardioversion at 0.5 to 1 J/kg, this can be increased to 2 J/kg if the first dose is not effective. Consider sedation for cardioversion as long as it does not cause a delay. Adenosine IV may be attempted if it does not delay electrical cardioversion and the rhythm is monomorphic. Seek expert cardiology consultation. Amiodarone or procainamide may be considered as treatment if initial treatment is unsuccessful.