Neonatal Arrhythmia

Birth History• ARB• Delivered via STAT Primary Cesarean Section for arrest in

cervical dilatation • 25 year old G1P1 (1001)• AOG: 38 5/7 weeks• MT: 39 AGA• Apgar Score: 9,9• Anthropometrics:

• BW= 2890 grams• BL= 47 cm• HC= 35 cm• CC= 32 cm• AC= 27 cm

• Maternal History: 1st Trimester, Cough and Colds, no medications given

• Past Medical History: Breast cyst, Left, s/p Excision(2012)

• Family History: Hypertension

• OB History: present pregnancy• Personal Social: College graduate, housewife, no vices

Upon Delivery

• Good cry and activity, no cyanosis• Clear amniotic fluid• Flat and open fontanelles• Good air entry, no retractions• Irregular cardiac rhythm, HR 140 bpm, no murmur

(skipped beats, 10 -13x per minute)• Soft Abdomen• Grossly normal female genitalia• Full pulses

Initial Impression

• Term Baby Girl• r/o Cardiac Pathology

PLAN:• Transfer to Level 3 of care hook to cardiac

monitor• Refer to a pediatric cardiologist– Hook to cardiac monitor– BP and oxygen saturations on all extremities

Course in the NICUSubjective Objective Assessment Plan- 3rd HOL- Good suck, cry,

and activity- Able to latch

- T: 36.8, HR 146, RR: 44

- No cyanosis, no alar flaring

- Good air entry, no retractions

- Irregular cardiac rhythm, with 1-2 skipped beats/minute

- Full pulses

Live term baby girlr/o cardiac pathology

- Monitor vital signs every hour

- Hook to cardiac monitor

- BP and O2 sats on all extremities

- Watch out for 25-30 skipped beats/minute

• Stable vital signs• BP on all extremities:

• Oxygen saturations on all extremities: 100%

61/31 63/38

65/30 61/35

Course in the NICUSubjective Objective Assessment Plan- 10th HOL- Good suck, cry,

and activity- Tolerates 10-

15ml of milk feedings

- T: 37, HR 122, RR: 44

- No cyanosis, no alar flaring

- Good air entry, no retractions

- Irregular cardiac rhythm, with 2-5 skipped beats/minute

- Full pulses

Live term baby girlr/o cardiac patholog

- Bed side 2D-echo

- EG-7

• 2D echo– PFO 4.2mm– Left to right shunt– Trivial mitral regurgitation– PDA 1.8 continuous blow– Normal transitional circulation; no arrhythmia

• Cardiology remarks:– Common incidental finding in newborns– Structural abnormality ruled out– No signs of heart failure noted– Refer for >5 skipped beats per minute

• EG7 results:– Na: 138 mmo/L– K: 4.3 mmo/L– iCal: 1.21 mmo/L– Hct: 47%– pH: 7.37– pCO2: 47 mmHg– pO2: 38mmHg (80-105)– HCO3: 27 mmo/L– TCO2: 28 mM– Beecf: 2 mM– sO2: 69% (95-98)– tHB: 16 g/dL

Course in the NICUSubjective Objective Assessment Plan- 24th HOL- Good suck, cry,

and activity- Tolerates 10-

15ml of milk feedings every 2 hours

- T: 36,5, HR 148, RR: 56

- No cyanosis, no alar flaring

- Good air entry, no retractions

- Regular cardiac rhythm, no skipped beats

- Full pulses

Live term baby girl - Rooming in

Course in the NICUSubjective Objective Assessment Plan- Day 2 of life- Good suck, cry,

and activity- Breastfeeding

- T: 36,5, HR 148, RR: 56

- No cyanosis, no alar flaring

- Good air entry, no retractions

- Regular cardiac rhythm, no skipped beats

- Full pulses

Live term baby girl - May go home- For ECG -

Normal

Neonatal Arrhythmias

• Arrhythmias in fetuses and newborns are relatively common -- up to 90% of newborns and 1% to 3% of pregnancies

• Life-threatening arrhythmias are uncommon

• Almost all arrhythmias fall into one of three categories– irregular– tachycardic– bradycardic

• Arrhythmias are found in 1–5% of newborns during the first 10 days of life

• Most are premature supraventricular beats that will disappear during the first month of life

• The development of symptoms depends on the rate and duration of the arrhythmia

• tachyarrhythmia - 240–300bpm• Bradyarrhythmia - <100bpm

Normal Newborn ECG

Sinus Pause

Sinus Arrhythmia

• Sinus pauses from 800 to 1,000 msec may occur in healthy newborns

• Such pauses usually are followed by escape beats from the atria or the atrioventricular (AV) junction

• Pauses of more than 2 seconds are considered abnormal

• Possible causes:– oversedation, (drugs passed through the placenta)– hypothermia– central nervous system abnormalities– increased intracranial pressure– increased vagal tone– obstructive jaundice– hypothyroidism