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Clinical Pearl: Pediatric SVT in Actual Practice

Emergency Medicine News: May 2017 - Volume 39 - Issue 5 - p 25
doi: 10.1097/01.EEM.0000516465.15639.3d
Clinical Pearl

BY EMEDHOME.COM

A new study of pediatric supraventricular tachycardia (SVT) describes actual management of such cases and illustrates how care often deviates from guideline recommendations. During the 10-year study period, 179 cases of pediatric SVT patients without a history of congenital heart disease were treated at a tertiary care facility:

  • A first dose of adenosine was effective in 56 percent of episodes, and a second dose was effective in 50 percent. Not all cases received adenosine (e.g., if spontaneous conversion occurred). This left 15 percent of episodes with refractory SVT. The response to the first dose of adenosine increased proportionally with age; only one of 17 episodes in infants responded to the first dose of adenosine.
  • Vagal maneuvers were attempted in 61 percent of episodes and were successful in 25 percent. Application of ice to the face and blowing in a blocked straw were the most successful vagal maneuvers.
  • Unstable SVT was present in 13 episodes, and all were treated initially with vagal maneuvers, all unsuccessful, and adenosine. Five of 13 patients converted to sinus rhythm after one to three doses of adenosine. Ultimately, 11 of the 13 unstable patients were managed with medications alone, contrary to AHA guidelines. This study indicates reluctance to electrically cardiovert pediatric patients, even among providers at a tertiary children's hospital.
  • Seven patients with refractory SVT left the ED in SVT and were admitted to the ICU. Various antiarrhythmic medications were used in these patients, most frequently digoxin and propranolol in infants and amiodarone and procainamide in older children. (J Pediatr 2017;181:177.)

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Amal Mattu, MD and Colleagues: An update on cardiac arrest, blood cultures in the ED, and the new sepsis guidelines: http://bit.ly/MattuEMN. Dr. Mattu is one of the premier speakers in emergency medicine and a professor of emergency medicine and the vice chair of emergency medicine at the University of Maryland School of Medicine in Baltimore.

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Sergey Motov, MD: Pain Management of Pregnant Patients in the ED, Part 2: http://bit.ly/EMN-EMedHomeVideos. Dr. Motov is an assistant professor of clinical emergency medicine at SUNY Downstate Medical Center and the assistant emergency medicine residency director at Maimonides Medical Center, both in New York City.

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