Paroxysmal supraventricular tachycardia: Difference between revisions
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===Stable===
===Stable===
*[[Vagal maneuvers]]
'''[[Vagal maneuvers]]'''
**Pediatrics: often successful with ice application to face
*Pediatrics: often successful with ice application to face
**Carotid sinus massage (ideal duration of 15 seconds<ref>Appelboam, A, et al. Randomised Evaluation of modified Valsalva Effectiveness in Re-entrant Tachycardias (REVERT) study. BMJ, 2014; 4(3):e004525.</ref>)
*Carotid sinus massage (ideal duration of 15 seconds<ref>Appelboam, A, et al. Randomised Evaluation of modified Valsalva Effectiveness in Re-entrant Tachycardias (REVERT) study. BMJ, 2014; 4(3):e004525.</ref>)
***Auscultate to r/o bruits in carotid artery before performing
**Auscultate to r/o bruits in carotid artery before performing
***Perform ONE side at a time
**Perform ONE side at a time
**Valsalva maneuver (ideal duration of 10 seconds)
*Valsalva maneuver (ideal duration of 10 seconds) and may be modified to be followed by laying the patient supine and performing passive leg raise to increase efficacy<ref>Appelboam A. et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial [http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736%2815%2961485-4.pdf fulltext]</ref>
*[[Adenosine]]
'''[[Adenosine]]'''
**6mg IVP; 12mg IVP (if initial dose failed)
*6mg IVP; 12mg IVP (if initial dose failed)
*Contraindicated in asthmatics
'''[[Calcium-channel blockers]]'''
*[[Diltiazem]] 15–20mg IV over 2min
**May give 25mg IV if inadequate response after 15min
**If IV bolus worked start IV infusion at 5–20mg/hr
**Contraindications: Hypotension, [[CHF]], any suspicion of VT
*[[Beta-blockers]]
**[[Metoprolol]] 5mg IV q5min x 3; give 50mg PO if IVP effective
**[[Esmolol]] 500mcg/kg IV over 60sec
***May give repeat bolus if inadequate response after 2-5min
***If effective start infusion at 50mcg/kg/min (titrate up to 300mcg/kg/min)
**Contraindicated in asthmatics
**Contraindicated in asthmatics
*[[Calcium-channel blockers]]
**[[Diltiazem]] 15–20mg IV over 2min
***May give 25mg IV if inadequate response after 15min
***If IV bolus worked start IV infusion at 5–20mg/hr
***Contraindications: Hypotension, [[CHF]], any suspicion of VT
**[[Beta-blockers]]
***[[Metoprolol]] 5mg IV q5min x 3; give 50mg PO if IVP effective
***[[Esmolol]] 500mcg/kg IV over 60sec
****May give repeat bolus if inadequate response after 2-5min
****If effective start infusion at 50mcg/kg/min (titrate up to 300mcg/kg/min)
***Contraindicated in asthmatics


==See Also==
==See Also==

Revision as of 17:09, 4 September 2015

SVT terminology can be confusing, as some references consider SVT to be any rhythm originating above the ventricles (i.e. sinus tachycardia, MAT, atrial flutter, atrial fibrillation, PSVT, etc). As these entities have their own specific articles and treatment, only paroxysmal supraventricular tachycardia links here.

Background

  • Also known as PSVT and frequently referred to just as SVT
  • AV nodal reentrant tachycardia (AVNRT) and AV reentrant tachycardia (AVRT) are subtypes of PSVT
  • Most common dysrhythmia in children
  • Infants: poor feeding, tachypnea, and irritability

Clinical Presentation

  • Palpitations
  • May also present with haemodynamic instability if severe, eg hypotension, syncope

Differential Diagnosis

Palpitations

Diagnosis

PSVT at ~180 bpm
Symptoms Sinus tachycardia SVT
History volume loss sudden onset
Physical Exam dehydated CHF-like
^Heart Rate <180 >180
Variability Yes No

^In infants HR cuttoff = 220

Treatment

Termination of PSVT following adenosine

Unstable

  • Synchronized cardioversion 0.5-1.0 J/kg
  • Pediatrics: cardioversion at 0.5-1 J/kg. If unsuccessful, increase to 2 J/kg
  • Consider giving sedation prior to cardioversion (unless in emergent situation)

Stable

Vagal maneuvers

  • Pediatrics: often successful with ice application to face
  • Carotid sinus massage (ideal duration of 15 seconds[1])
    • Auscultate to r/o bruits in carotid artery before performing
    • Perform ONE side at a time
  • Valsalva maneuver (ideal duration of 10 seconds) and may be modified to be followed by laying the patient supine and performing passive leg raise to increase efficacy[2]

Adenosine

  • 6mg IVP; 12mg IVP (if initial dose failed)
  • Contraindicated in asthmatics

Calcium-channel blockers

  • Diltiazem 15–20mg IV over 2min
    • May give 25mg IV if inadequate response after 15min
    • If IV bolus worked start IV infusion at 5–20mg/hr
    • Contraindications: Hypotension, CHF, any suspicion of VT
  • Beta-blockers
    • Metoprolol 5mg IV q5min x 3; give 50mg PO if IVP effective
    • Esmolol 500mcg/kg IV over 60sec
      • May give repeat bolus if inadequate response after 2-5min
      • If effective start infusion at 50mcg/kg/min (titrate up to 300mcg/kg/min)
    • Contraindicated in asthmatics

See Also

Source

  1. ↑ Appelboam, A, et al. Randomised Evaluation of modified Valsalva Effectiveness in Re-entrant Tachycardias (REVERT) study. BMJ, 2014; 4(3):e004525.
  2. ↑ Appelboam A. et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial fulltext
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