Ice water immersion, other vagal manoeuvres or adenosine for SVT in children
Date First Published:
December 13, 2015
Last Updated:
April 26, 2017
Report by:
Marion Campbell, Consultant in Emergency Medicine (Hairmyres Hospital, NHS Lanarkshire, Scotland, UK)
Search checked by:
Silvia Ruiz Buitrago,, Hairmyres Hospital, NHS Lanarkshire, Scotland, UK
Three-Part Question:
In [children with SVT] which [intervention] is most likely to [terminate SVT]?
Clinical Scenario:
An 8-year-old girl presents to the paediatric ED with palpitations. She is not distressed, and has a normal BP, but her pulse is 200 beats per minute. An ECG reveals supraventricular tachycardia. If she were an adult, you would try the posturally modified Valsalva manoeuvre and then reach for the adenosine, but you wonder what evidence there is for this or other vagal manoeuvres in children and, indeed, what evidence there is for the use of adenosine.
Search Strategy:
Ovid MEDLINE(R) 1946–Week 2, November 2016: [(supraventricular tachycardia.mp.) OR (exp Tachycardia, Supraventricular) OR (SVT.mp.) OR (exp Tachycardia, Atrioventricular Nodal Reentry) OR (narrow complex tachycardia.mp.) OR (junctional tachycardia.mp)] AND [(vagal manoeuvre$.mp.0 OR (vagal manoeuvre$.mp.) OR (exp Diving Reflex) OR (exp Immersion/or immersion.mp) OR (exp Valsalva Maneuver) OR (valsalva.mp.)] AND [(exp Child) OR (child$.mp.) OR (paediatric.mp.) OR (exp paediatrics) OR (pediatric.mp.) or (exp paediatrics)]
Embase 1980–2016, Week 46: supraventricular tachycardia.mp. or exp supraventricular tachycardia/ OR SVT.mp OR narrow complex tachycardia.mp.OR junctional tachycardia.mp. OR exp atrioventricular nodal re-entry tachycardia/AND vagal manoeuvre$.mp OR vagal manoeuvre$.mp OR diving reflex.mp.OR Immersion.mp. or exp immersion/ OR valsalva.mp. OR exp Valsalva maneuver/limit 14 to (human and English language), yr=’2012–Current’ (infant <to one year> or child <unspecified age> or preschool child <1 to 6 years> or school child <7 to 12 years> or adolescent <13 to 17 years>)
The Cochrane Library date of searching 18 November 2016: MeSH descriptor: [Tachycardia, Supraventricular] explode all trees AND MeSH descriptor: [Child] explode all trees OR MeSH descriptor: [Pediatrics] explode all trees
Embase 1980–2016, Week 46: supraventricular tachycardia.mp. or exp supraventricular tachycardia/ OR SVT.mp OR narrow complex tachycardia.mp.OR junctional tachycardia.mp. OR exp atrioventricular nodal re-entry tachycardia/AND vagal manoeuvre$.mp OR vagal manoeuvre$.mp OR diving reflex.mp.OR Immersion.mp. or exp immersion/ OR valsalva.mp. OR exp Valsalva maneuver/limit 14 to (human and English language), yr=’2012–Current’ (infant <to one year> or child <unspecified age> or preschool child <1 to 6 years> or school child <7 to 12 years> or adolescent <13 to 17 years>)
The Cochrane Library date of searching 18 November 2016: MeSH descriptor: [Tachycardia, Supraventricular] explode all trees AND MeSH descriptor: [Child] explode all trees OR MeSH descriptor: [Pediatrics] explode all trees
Outcome:
After duplicates and non-English language citations were removed, 40 papers remained, 5 of which were relevant. A hand search of these 40 remaining citations identified a further 8 relevant papers. Review of the Cochrane database of systematic reviews did not reveal any papers. Using the same strategy, the checker identified one further paper. These 14 papers are presented in the table
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The diving reflex in termination of supraventricular tachycardia in children. Whitman V and Zakesian GM. 1976 USA | 8 year old girl with SVT resistant to several other treatments, had head immersed in bucket of water. | Case report (4) | Cardioversion to Sinus Rhythm | This was the first written account of using the diving reflex to cardiovert children with SVT | |
| Supraventricular tachycardia in newborn infants: an approach to therapy. Whitman V , Friedman Z , Berman W Jr , et al . 1977 USA | Two neonates with SVT and cardiac congestion, had heads immersed in ice water for 4-5 seconds | Case series (4) | Cardioversion to Sinus Rhythm | Ice-water immersion: 2/2 (100%) | No comment on how or why these infants were selected for this treatment. |
| The ice bag: a new technique for interruption of supraventricular tachycardia. Bisset GS III , Gaum W , Kaplan S . 1980 USA | Ten children presenting with paroxysmal SVT, treated with an ice-bag to face with breath held, until cardioversion or up to 15 secs, whichever shorter. | Case series (4) | Cardioversion to Sinus Rhythm | Ice-bag to face: 10/10 (100%) | No comment on how children were selected for ice-water treatment. No treatment failure suggests some selection bias. Children also asked to breath-hold so this may introduce confounder. |
| Initiation of the diving reflex in neonates with supraventricular tachycardia. Van Der Horst RL and Harstreiter AR 1980 USA | Two neonates, both presenting with SVT, treated with “an ice cube to the nasal bridge” | Case series (4) | Cardioversion to Sinus Rhythm | Ice-water: 1/2 (50%) | No comment on how why these infants were selected for this treatment. |
| Supraventricular tachycardia in infants: response to initial treatment. Sreeram N and Wren C 1980 UK | 29 infants treated in the North East of England between 1977 and 1988 for SVT. | Case series (4) | Cardioversion to Sinus Rhythm | Ice-water to face: 53/59 (90%) | No specific protocol applied, no comment on presence of pre-existing cardiac disease |
| Cardioversion to Sinus Rhythm | Adenosine: 1/1 (100%) | ||||
| Cardioversion to Sinus Rhythm | Digoxin: 11/14 (79%) | ||||
| Cardioversion to Sinus Rhythm | Verapamil: 3/3 (100%) NB: One fatal overdose | ||||
| Cardioversion to Sinus Rhythm | DC Cardioversion: 6/10 (60%) | ||||
| Supraventricular tachycardia in children: clinical features, response to treatment, and long-term follow up in 217 patients. Garson A Jr , Gillette PC , McNamara DG . S. 1981 USA | 217 children’s first episode of SVT | Retrospective cohort study (2b) | Cardioversion to Sinus Rhythm | Digoxin: 90/142 (63%) | Data missing in 20 patients. |
| Cardioversion to Sinus Rhythm | DC Cardioversion: 12/20 (60%) | ||||
| Cardioversion to Sinus Rhythm | Vagal manoeuvres: 12/19 (63%) | ||||
| Cardioversion to Sinus Rhythm | Atrial overdrive pacing: 4/5 (80%) | ||||
| Supraventricular tachycardia in infants: use of the diving reflex. Sperandeo V , Pieri D , Palazzolo P , et al . 1982 Italy | 10 infants with spontaneous SVT refractory to induced emesis, eyeball pressure and carotid sinus massage, had face immersed in basin of cold water (4-5°C) for 6-7 secs. | Case series (4) | Cardioversion to Sinus Rhythm | Ice-water immersion: 10/10 (100%) | Mixed patient group. |
| Adenosine triphosphate treatment for supraventricular tachycardia in infants. De Wolf D , Rondia G , Verhaaren H , et al . 1994 Belgium | 22 infants in ED or ICU with SVT after failure of vagal manoeuvres, given Adensine 0.05mg/kg in incremental doses up to 1mg/kg | Retrospective cohort study (4) | Cardioversion to Sinus Rhythm | Adenosine: 17/22 (77%) | Hetrogenous group, no control, change in protocol during study period, |
| Vagal maneuvers and adenosine for termination of atrioventricular reentrant tachycardia. Müller G . Deal BJ , Benson DW Jr . et al. 1994 USA | 49 patients aged 1 day to 18 years with artificially induced SVT, then terminated with, ice to face, vagal manoeuvres and Adenosine | Retrospective cohort study (4) | Cardioversion to Sinus Rhythm | Ice-bag to face: 9/46 (20%) | Heterogenous group; no control, protocol applied variably, artificially induced SVT. |
| Cardioversion to Sinus Rhythm | Valsalva: 10/22 (45%) | ||||
| Application of ice water to the face in initial treatment of supraventricular tachycardia. Aydin M , Baysal K , Küçüködük S , et al . 1995 Turkey | Ten patients, some with multiple episodes of SVT. Faces of children immersed in ice-water for 5 seconds. | Case series (4) | Cardioversion to Sinus Rhythm | Ice-water immersion: 27/28 (96%) | No comment on how children were selected for ice-water treatment or other treatment. Little comment on heterogeneity of patient group. |
| Five paediatric case reports of the use of adenosine in supraventricular tachycardia. Koh E , Chan I , Wong KY . 1998 Singapore | Five patients, each given up to three doses of adenosine for SVT. Max dose 0.2mg/kg. | Case series (4) | Cardioversion to Sinus Rhythm | Adenosine: 5/5 (100%) | Described as a prospective cohort study but no details of excluded children given, so ultimately can only be taken as a case series. |
| Adenosine in the management of supraventricular tachycardia in children Sherwood MC , Lau KC , Sholler GF , et al . 1998 Australia | 32 children aged 1 day to 16 years, with spontaneous SVT in whom ice water immersion or Valsalva had failed, were given up to 0.3mg/kg Adenosine. | Case series (4) | Cardioversion to Sinus Rhythm | Ice-water immersion: (31/32) 97%. Sustained in only (23/32) 71%. | Heterogenous group which contained children with congenital heart disease who may respond differently. |
| Supraventricular tachycardia in children: a report of three cases, diagnosis and current management. Venugopalan P , Shakeel A , Al Amry A , et al . 2000 Oman | 3 girls aged 4, 5 and 9, presenting with SVT | Case series (4) | Caridoversion to Sinus Rhythm | All three children successfully cardioverted with adenosine. (100%) | Heterogenous group, dose and treatment details missing, no comment on side-effects |
| Paediatric arrhythmias in the emergency department. Clausen H , Theophilos T , Jackno K , et al 2012 Australia | 288 children (<18yrs) presenting to an ED with “non-arrest” arrhythmias. Of these, of which 135 were SVTs (total 250 presentations) | Retrospective cohort study (2b)t | Cardioversion to Sinus Rhythm | Adenosine: 64/82 (78%). | Lack of definition and success rate of vagal manoeuvres |
Author Commentary:
The evidence on the management of SVT in children is made up of poor-quality retrospective cohort studies or case series. There are no controlled studies; so, it is difficult to compare one treatment with another. Brief (5 s) immersion of the face in ice water to induce the dive reflex appears to be safe, quick, effective and non-invasive, although a little uncomfortable. Adenosine also appears to be safe and effective, but is more invasive. The effect of vagal manoeuvres such as Valsalva or carotid sinus massage in children has only been quantified once, and has a moderate success rate. No papers reported side effects from vagal manoeuvres. There is insufficient evidence to support the use of other therapies (digoxin, DC cardioversion, atrial pacing) as a first-line treatment.
Bottom Line:
Ice water to the face appears to be a safe, quick, effective and non-invasive treatment for paediatric SVT. Adenosine also appears safe and effective, but more invasive. Valsalva and carotid sinus massage are less effective.
References:
- Whitman V and Zakesian GM.. The diving reflex in termination of supraventricular tachycardia in children.
- Whitman V , Friedman Z , Berman W Jr , et al . . Supraventricular tachycardia in newborn infants: an approach to therapy.
- Bisset GS III , Gaum W , Kaplan S . . The ice bag: a new technique for interruption of supraventricular tachycardia.
- Van Der Horst RL and Harstreiter AR. Initiation of the diving reflex in neonates with supraventricular tachycardia.
- Sreeram N and Wren C. Supraventricular tachycardia in infants: response to initial treatment.
- Garson A Jr , Gillette PC , McNamara DG . S.. Supraventricular tachycardia in children: clinical features, response to treatment, and long-term follow up in 217 patients.
- Sperandeo V , Pieri D , Palazzolo P , et al . . Supraventricular tachycardia in infants: use of the diving reflex.
- De Wolf D , Rondia G , Verhaaren H , et al .. Adenosine triphosphate treatment for supraventricular tachycardia in infants.
- Müller G . Deal BJ , Benson DW Jr . et al. . Vagal maneuvers and adenosine for termination of atrioventricular reentrant tachycardia.
- Aydin M , Baysal K , Küçüködük S , et al . . Application of ice water to the face in initial treatment of supraventricular tachycardia.
- Koh E , Chan I , Wong KY . . Five paediatric case reports of the use of adenosine in supraventricular tachycardia.
- Sherwood MC , Lau KC , Sholler GF , et al .. Adenosine in the management of supraventricular tachycardia in children
- Venugopalan P , Shakeel A , Al Amry A , et al .. Supraventricular tachycardia in children: a report of three cases, diagnosis and current management.
- Clausen H , Theophilos T , Jackno K , et al . Paediatric arrhythmias in the emergency department.