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Children under the age of 5 years can sustain a sinus tachycardia at much higher rates (up to 225/minute) in response to physiological stresses. Look for hypovolemia, hypercarbia, and hypoxemia in stable children with narrow‐complex tachydysrhythmia before drug therapy is used. A volume challenge with 10 to 20 mL/kg of Ringer’s solution or another isotonic fluid IV is often useful before other therapies.

Figure 10.1 The classic one‐lead ECG appearance (lead II here) of torsades de pointes.

Note the shifting of the QRS complex axis and appearance.

Some guidelines make a distinction between energy levels when performing synchronized versus unsynchronized countershock. To keep treatments simple but effective, unstable children deserve countershock with 2 J/kg. Antidysrhythmic principles are otherwise like those outlined previously, with agents given in the appropriate weight‐based doses. Pediatric noncardiac arrest bradycardias are also usually secondary to another cause, often respiratory distress or hypoxia. When symptomatic, treat these rhythms primarily with epinephrine and airway maneuvers. There is rarely a need for transcutaneous pacing or atropine (0.02 mg/kg/dose).