ARRHYTHMIAS

Summary


These are classified as

1 Broad complex (ventricular) arrhythmias
2 Narrow complex arrhythmias
3 Heart block

Urgent treatment is only indicated if there are signs of associated hypotension or
cardiac failure. The most common cause in neonates is an electrolyte disturbance
(hyperkalaemia, hypocalcaemia).

If there is haemodynamic compromise, contact neonatal consultant immediately.
Always inform consultant neonatologist before contacting consultant cardiologist.

1. Broad QRS complex (ventricular) arrhythmias
QRS-T complexes which are different in configuration and polarity from those in
sinus rhythm and usually, but not necessarily, broad .
Most important causes are:

Hyperkalaemia
Hypoxaemia
Acidosis

Other associations are: cardiomyopathies, myocarditis, intracardiac tumours; rarely
structural heart disease or familial long QT syndrome.

The three types are ventricular extrasystoles (VEs) (common), ventricular
tachycardia (VT) (rare), and ventricular fibrillation (VF) (rare and usually fatal).

a. Ventricular extrasystole/ectopics (VEs)
Premature abnormal QRS complexes without a preceding P wave, sometimes
followed by a compensatory pause. These are common and occur in up to 33% of
healthy newborns [Southall 1980]. They are rarely a sign of cardiac disease.




Action
Occasional unifocal VEs:
no immediate action. Usually resolve within 2 months.
Very frequent VEs:
Look for positive family history, abnormal cardiac signs or ECG
abnormality.
Check electrolytes (particularly potassium).
Discuss with neonatal consultant



b. Ventricular Tachycardia (VT)

VT is a series of ventricular ectopics occurring sequentially at a rate of 150-250 /min.
It is rare. It may be paroxysmal or sustained. May be associated with underlying
cardiac disease or with a structurally normal heart.




Action

Discuss with neonatal consultant
Exclude hypoxia, hypovolaemia, tension pneumothorax and cardiac tamponade.
Check electrolytes in particular potassium and calcium .


If plasma potassium >7 mmol/l, administer salbutamol intravenously (4mg/kg) and
calcium gluconate (0.5ml/Kg of 10% calcium gluconate) to stabilise membrane
excitability. If potassium remains raised or recurrent ECG abnormalities repeat
salbutamol and consider glucose and insulin infusion. Correct any coexisting
acidosis (correction of hyperkalaemia is only a holding measure prior to
possible early recovery or commencement of dialysis)



If VT with no palpable pulse, commence CPR with adrenaline and DC shock with 4
joules/kg every 2 minutes with continuing CPR. One paddle over apex, other at right
sternal border; ensure no electrode gel bridges gap between paddles.

The defibrillator on the resuscitation trolley on the delivery suite may be used for this
purpose.






c. Ventricular Fibrillation

VF comprises fast, bizarre QRS complexes. Rare in neonates.







Action:
Discuss with neonatal consultant
Commence CPR including adrenaline and DC shock (4 joule/kg every 2 minutes
with continuing CPR). One paddle over apex, other at right sternal border

Correct underlying abnormality:
Hyperkalaemia
Hypoxaemia
Acidosis


2. Narrow QRS complex (supraventricular) arrhythmias
The commonest form of supraventricular tachycardia (SVT) in neonates is an AV re-
entry tachycardia. Heart rate is between 180-300 /min. May have been present
prenatally (fetal tachycardia hydrops fetalis). Distinguish from sinus tachycardia
(max normal HR is c 220 /min when crying).




Underlying abnormalities: heart usually anatomically normal, but 10% have Wolff-
Parkinson-White syndrome (as shown). Rarely: Ebsteins anomaly, cardiac tumours,
myocarditis, electrolyte disturbances (hyperkalaemia, hypocalcaemia)

Infants may be asymptomatic or show signs of failure: pallor, breathlessness,
hepatomegaly, oedema, gallop rhythm.

Action:
Discuss with neonatal consultant
a. SVT + no haemodynamic compromise (no hypotension)

Action:
Vagal manoeuvres, adenosine.

(a) Vagal stimulation: Gentle massage over one carotid body. Eyeball pressure
must not be used because of risk of retinal detachment.

(b) Facial cooling: fill a plastic bag with ice cubes and place over face (forehead,
eyes, nose, mouth, cheeks) for about 15 s.

(c) Try adenosine rapidly IV + saline flush immediately afterwards.
Start at low dose and increase at 2-min intervals up to max dose of 300 micrograms
per kilogram

Starting dose 50 micrograms /kg
Then 100 micrograms/kg
Then 150 micrograms /kg
Then 200 micrograms /kg
Then 250 micrograms /kg
Then 300 micrograms /kg

Adenosine impairs AV conduction. Very effective in treatment of SVT. Short (15 s)
half-life without myocardial depression. Side-effects: profound sinus bradycardia, AV
block.

b. SVT + haemodynamic compromise (hypotension)

Action:
Discuss with neonatal consultant
Adenosine or DC shock, whichever is closest to hand

(a) If baby is hypotensive DC shock with 1 joule/kg repeat with 2 joules/kg if
ineffective.

(b) Only after discussion with cardiologist:
Flecainide return to sinus rhythm usually within 10 min; side-effects
transient hypotension and vomiting
Amiodarone - will work if the diagnosis is SVT or VT. It has little

negative
inotropic effect, so it is relatively

safe when myocardial

function may be
compromised.
Digoxin - only after discussion with cardiologist and consultant neonatologist
See formulary for doses

c. Recurrent SVT
Discuss with cardiologist and consider other agents (e.g. flecainide, digoxin etc)

d. Sinus tachycardia
Always secondary, e.g. to infection, shock. Other forms of SVT (atrial flutter or
fibrillation) are rare in neonates.

e. Sinus bradycardia
May normally occur asleep or when straining but a sustained rate below 80 /min in
term and 100 /min in preterm infants is abnormal. Most commonly seen with
apnoeas but also with hypoxia, raised intracranial pressure, convulsions,
hyperkalaemia, hypothyroidism and as a side effect of drugs (e.g. heavy sedation,
digoxin, propranolol)

3. Heart block
In complete (third degree) heart block there is dissociation between P waves and
QRS complexes with idioventricular rate 40-80 /min. May occur with complex
structural heart lesions or normal cardiac structure with His bundle fibrosis due to
maternal antibodies (e.g. anti-Ro) and maternal SLE or post-atrial septostomy.
Action: 12 lead ECG. Check maternal anti-Ro status.

Action: Discuss with consultant neonatologist
.
If resting heart rate below 55 /min and/or heart failure:
(a) Diuretics
(b) Chronotrope infusion - isoprenaline
(c) Temporary pacing

References
Southall DP et al. Study of cardiac rhythm in healthy newborn infants. British Heart
Journal 1980; 43: 14-20

Sreeram N, Wren C. Supraventricular tachycardia in infants: response to initial
treatment. Arch Dis Child 1990; 65: 127-129.
March 31st 2009 (version 5-NICU79)
Kothari DS, Skinner JR. Neonatal tachycardias: an update. Arch Dis Child Fetal
Neonatal Ed. 2006 Mar;91(2):F136-44. Review.


November 2nd 2010 (version 6-NICU79)