top of page

Pediatric Advanced Life Support (PALS) Tachycardia Algorithm Overview

Updated: Dec 3, 2021

The initial management of Pediatric Tachycardia includes the following:

Airway: Support the Airway and position the child or allow the child to assume a position of comfort or Open, Maintain and Protect the airway if needed.

Breathing: Give oxygen in high concentration like using a non-rebreather mask if available. Assist ventilations as indicated using a bag-Mask device and ensure to attach a pulse oximeter to monitor the oxygen saturation.

Circulation: Check the Heart rate and Blood Pressure. Attached an ECG monitor or defibrillator.

Establish vascular access using IV or IO and obtain appropriate laboratory studies.

Assess Neurologic status.

Perform a 12-lead ECG if available, but it should not delay treatment.

Evaluate the 12-lead ECG. Determine if the rhythm is a Sinus Tachycardia or a Tachyarrhythmia.

In Sinus Tachycardia, we should see P Waves which are normal looking with an Infant rate below 220/min and a child rate below 180 per minute. We should also search for and treat the causes.

Signs of Cardiopulmonary compromise include:

•Acutely altered mental status

•Signs of Shock


Treatments vary, based on the width of the QRS complex. Narrow, it means that the QRS is equal or less than 0.09 seconds or Wide when the QRS is more than 0.09 seconds.

If narrow complex, treat as a probable SVT. We would typically see when it’s an SVT that the P waves are absent, Infant rate equal or above 220 per minute, and in children a rate equal or above 180 per minute.

If the patient has a stable SVT, consider Vagal Maneuvers. Vagal Maneuvers help to decrease the heart rate when the Vagus nerve is stimulated. In patients with SVT, vagal stimulation may terminate the tachycardia by slowing the conduction through the AV node. The easiest technique to use in both infants and children is to put Ice on the face. Apply a small plastic bag filled with ice and water to the upper half of the face for 15-20 seconds and Do not occlude the nose and mouth. Older children that are old enough to follow instructions can perform the Valsalva maneuver by blowing through a narrow straw. It’s important to never use ocular pressure as it may produce retinal injury. If the child remains stable and the rhythm does not convert, we can try it for a second time.

After a second attempt and it does not work, we can try a different method or make use of medications. If the patient becomes unstable at any time, consider Synchronized Cardioversion.

It’s important to monitor and record the ECG continuously before, during, and after attempted vagal maneuvers.

If Vagal Stimulation was not successful and an IV/IO is present, give Adenosine.

If the QRS is greater than 0.09 seconds, treat it as a possible Ventricular Tachycardia (VT) If the patient is stable and the rhythm is regular and QRS monomorphic, consider adenosine. Avoid adenosine if the rhythm is irregular as this may result in an unstable rhythm. Expert consultation is recommended. If a child with a wide-complex tachycardia is hemodynamically stable, early consultation with a pediatric cardiologist or other providers with appropriate expertise is strongly recommended

For Pharmacologic Conversion:

Establish vascular access and consider administering one of the following medications:

  • Amiodarone: For IV/IO route, give 5 mg/kg over 20 to 60 minutes.

  • Procainamide: For IV/IO route, give 15 mg/kg over 30 to 60 minutes.

Seek expert consultation when giving Amiodarone or Procainamide. Do not routinely administer Amiodarone and Procainamide together or with other medications that prolong the QT interval. If these initial efforts do not terminate the rapid rhythm, reevaluate the rhythm.

If not already administered, consider adenosine, because a wide-complex tachycardia could be SVT with aberrant ventricular conduction

If the patient is unstable with a possible VT, perform Synchronized Cardioversion.

Disclaimer: This video is for educational purposes only, and is not intended as medical advice. While we strive for 100% accuracy, errors may occur, and medications or protocols may change over time.



bottom of page