10.3 Antiarrhythmics for Tachycardia with Pulse

AHA PALS Provider Pediatric Advanced Life Support

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1 Chapter 1: Course Overview & Exam Logistics

1.1 Current Exam Facts 1.2 Audience, Prerequisites & Study Plan

2 Chapter 2: Systematic Pediatric Assessment

2.1 Pediatric Assessment Triangle (PAT) 2.2 Evaluate–Identify–Intervene Sequence 2.3 Primary Assessment: ABCDE 2.4 Secondary Assessment, SAMPLE & Vitals by Age

3 Chapter 3: Respiratory Distress & Failure

3.1 Respiratory Distress vs Failure 3.2 Recognition & Immediate Intervention Priorities 3.3 Oxygen Delivery & Basic Airway Support

4 Chapter 4: Airway Problems & Ventilation Strategies

4.1 Upper Airway Obstruction 4.2 Lower Airway, Lung Tissue Disease & Disordered Control 4.3 Bag-Mask Ventilation & Advanced Airways During CPR

5 Chapter 5: Shock Fundamentals & Hypovolemia

5.1 Compensated vs Hypotensive (Decompensated) Shock 5.2 Hypovolemic Shock 5.3 Isotonic Fluid Bolus 10–20 mL/kg & Reassessment

6 Chapter 6: Distributive, Cardiogenic & Obstructive Shock

6.1 Distributive & Septic Shock Pathway 6.2 Cardiogenic Shock 6.3 Obstructive Shock

7 Chapter 7: Pediatric BLS & High-Quality CPR

7.1 High-Quality CPR Metrics 7.2 Compression-Ventilation Ratios 7.3 CPR Quality Monitoring: ETCO2 & Diastolic BP

8 Chapter 8: Pediatric Cardiac Arrest Algorithm

8.1 Arrest Recognition & Systematic Approach 8.2 VF/pVT & Defibrillation Energy 8.3 Asystole & PEA 8.4 Epinephrine in Arrest: Dose & Timing

9 Chapter 9: Bradycardia & Narrow-Complex Tachycardia

9.1 Bradycardia with Poor Perfusion 9.2 Sinus Tachycardia vs SVT 9.3 Stable SVT: Vagal Maneuvers & Adenosine

10 Chapter 10: Unstable Tachycardia & Wide-Complex Rhythms

10.1 Unstable Tachycardia & Synchronized Cardioversion 10.2 Wide-Complex Tachycardia & VT with Pulse 10.3 Antiarrhythmics for Tachycardia with Pulse

11 Chapter 11: Reversible Causes & Special Circumstances

11.1 Reversible Causes: The H's and T's 11.2 Special Circumstances at Exam Level 11.3 Extracorporeal CPR (ECPR) Overview

12 Chapter 12: Post–Cardiac Arrest Care

12.1 Post-ROSC Oxygenation & Ventilation 12.2 Post-Arrest Hemodynamic Support 12.3 Temperature Control & Glucose 12.4 Neuroprognostication & Transport

13 Chapter 13: Vascular Access & Core Pharmacology

13.1 IV and Intraosseous Access 13.2 Epinephrine Dosing in Depth 13.3 Amiodarone, Lidocaine & Adenosine 13.4 Weight-Based Dosing Aids & Drugs to Avoid Routinely

14 Chapter 14: Team Dynamics & Megacode Readiness

14.1 High-Performance Team Roles 14.2 Closed-Loop Communication 14.3 Constructive Intervention, Debriefing & Exam Integration

10.3 Antiarrhythmics for Tachycardia with Pulse

Key Takeaways Explain This Topic AI

For perfusing (pulse-present) VT, amiodarone is commonly taught as 5 mg/kg IV/IO given over a period of time (infusion), not as the same rapid arrest-style push used in cardiac arrest contexts.

Procainamide is an alternative antiarrhythmic used in some protocols for stable/perfusing VT; expert consultation should guide selection and infusion monitoring.

Lidocaine is another option in VT algorithms depending on local PALS/protocol pathways—know that alternatives exist, not only one brand-name drug.

Prefer expert consultation; do not casually stack multiple antiarrhythmics (e.g., amiodarone plus procainamide) because of additive proarrhythmic and hemodynamic risk.

Adenosine remains for regular monomorphic narrow-complex SVT (and carefully selected situations)—it is not the interchangeable first drug for undifferentiated VT with pulse.

Last updated: August 2026

Where Drugs Fit After Electricity and Expert Judgment

Antiarrhythmic medications for tachycardia with a pulse sit in a different mental box from cardiac arrest drugs. In arrest (Chapter 8), the priorities are CPR, defibrillation for VF/pVT, and epinephrine timing. Antiarrhythmics for refractory shockable arrest are given in a bolus context during CPR. In perfusing VT or other stable/near-stable wide-complex rhythms, the goals shift to terminating or suppressing the arrhythmia without crashing blood pressure , often with controlled infusions and continuous monitoring—preferably under expert consultation .

Before any infusion:

Confirm a pulse is present.

Decide stable vs unstable . Unstable → synchronized cardioversion first (Section 10.1), not a 20-minute drug prep.

Support ABCs; pads remain on the chest.

Correct obvious reversible causes when feasible (electrolytes, toxins, hypoxia).

Call for pediatric cardiology / critical care / EP help early.

Drugs buy time and may convert rhythm; they do not replace airway support, electricity when indicated, or diagnosis of the underlying disease (myocarditis, channelopathy, congenital heart disease, drug toxicity).

Arrest bolus vs pulse-present infusion — the amiodarone distinction

Amiodarone 5 mg/kg IV/IO appears in both worlds, but how you give it changes with context:

Context Typical teaching administration Why

Cardiac arrest (refractory VF/pVT) Rapid IV/IO bolus during CPR No effective output; need fast myocardial delivery

Perfusing VT / tachycardia with pulse 5 mg/kg IV/IO over a period of time (infusion over minutes, not an instant code-style slam in a child with a pulse) Rapid boluses can cause severe hypotension when a pulse is still present

On the exam, if the vignette says VT with a pulse and asks for amiodarone dosing concept, answer 5 mg/kg and recognize infusion/over-time administration—not “push it like epinephrine in asystole.” Exact infusion durations can vary by protocol and formulation; PALS-level mastery is the dose number + pulse-present vs arrest technique distinction .

Core Agents for Perfusing VT (Exam-Level)
Amiodarone
Dose teaching point: 5 mg/kg IV/IO
Use case: Ventricular arrhythmias / wide-complex VT pathways when drugs are indicated
Pulse-present key: give over time (infusion), monitor BP and rhythm continuously
Risks: hypotension, bradycardia, further arrhythmias; long half-life complicates stacking other agents

May be repeated per protocol/expert guidance up to cumulative limits taught in provider materials—do not invent unlimited redosing on your own

Procainamide
Role: Alternative antiarrhythmic for stable/perfusing VT or certain supraventricular scenarios in expert hands

Why alternatives exist: Some rhythms or patient factors favor procainamide over amiodarone (and vice versa); local protocols and cardiology preference matter

Practical exam point: Know that procainamide is an accepted alternative where used—not that every learner must memorize every adult milligram-per-minute chart for the PALS written exam

Cautions: Hypotension, QRS widening, proarrhythmia; infusion requires monitoring; avoid casual combination with amiodarone

Lidocaine

Role: Another option in ventricular arrhythmia algorithms (including some arrest and peri-arrest pathways depending on guideline/protocol generation and local practice)

Exam framing: If a question lists lidocaine among antiarrhythmic choices for VT, recognize it as a legitimate class option , while still applying the stable/unstable and pulse/pulseless branches first

Cautions: CNS toxicity (seizures, altered mentation) at high levels; dose adjustments in low cardiac output states per protocol

Comparison snapshot

Drug Highest-yield PALS teaching point for tachycardia with pulse
Amiodarone 5 mg/kg IV/IO over time for perfusing VT (contrast arrest bolus)
Procainamide Alternative agent; expert/protocol-guided infusion
Lidocaine Alternative ventricular antiarrhythmic; 1 mg/kg IV/IO loading dose on the 2025 arrest algorithm
Adenosine Not the VT drug—used for regular monomorphic narrow SVT (0.1 then 0.2 mg/kg rapid push)
Magnesium Torsades / polymorphic VT with long-QT context (Section 10.2)
Do not stack antiarrhythmics casually

Giving amiodarone and procainamide together (or piling multiple agents without expertise) increases risk of:

Severe hypotension
Proarrhythmia (including bradycardia, heart block, or degeneration to VF)
Inability to tell which drug caused deterioration
Delayed electricity or expert care while “one more drug” is mixed

Preferred pattern: choose one pharmacologic strategy under protocol/expert guidance, reassess, and escalate to cardioversion if the child becomes unstable or the rhythm is refractory. If the first agent fails and the child remains stable enough, expert consultation—not reflexive dual loading—should drive the next agent.

Loading diagram... Antiarrhythmics with Pulse vs Other Pathways

Contrast: Adenosine for SVT vs Antiarrhythmics for VT

Mixing these pathways is one of the most common pharmacology errors on resuscitation exams.

Adenosine pathway (Chapter 9 reminder)
Rhythm: Regular, monomorphic, narrow-complex SVT (reentry involving AV node)

Stability: Used when the child is stable enough for a chemical attempt (or as part of the standard stable pathway); unstable SVT → cardioversion

Dose: 0.1 mg/kg rapid IV/IO push + flush, then 0.2 mg/kg if needed (common teaching maxima 6 mg / 12 mg)
Technique: Speed matters more than ceremony—ultrashort half-life

Not for: Irregular wide-complex tachycardia, known pre-excited AF, or as a substitute for defibrillation in pVT

VT / wide-complex antiarrhythmic pathway (this section)
Rhythm: Presumed or confirmed VT / selected wide-complex rhythms with pulse
Stability: Unstable → electricity first; stable → expert + single-agent strategy
Amiodarone teaching dose: 5 mg/kg IV/IO over time for perfusing VT
Alternatives: Procainamide, lidocaine per protocol
Not interchangeable with adenosine as a first-line “rate reset” for VT

Feature Stable narrow SVT Perfusing monomorphic VT
First specialized med (typical) Adenosine after vagal Amiodarone/procainamide/lidocaine options
Delivery Rapid push + flush Controlled infusion / protocol timing
If unstable Synchronized cardioversion Synchronized cardioversion
If pulseless Not the primary path—if VF/pVT, defibrillate Defibrillate + CPR
Practical monitoring while infusions run
Continuous ECG; watch for conversion, QRS widening, bradycardia, or degeneration to VF
Frequent blood pressure; be ready to stop the infusion and support perfusion
Defibrillator charged conceptually “one button away”—know the next energy if the child crashes
Document times, doses, and rhythm strips
After conversion: search etiology, consider ICU/cardiology admission, avoid premature removal of pads
Clinical scenarios (synthesis)

Scenario A — Perfusing VT, stable enough for meds: A 9-year-old is alert with acceptable blood pressure and a regular wide tachycardia thought to be monomorphic VT. Pads are applied. Cardiology recommends amiodarone. You administer amiodarone 5 mg/kg IV over the protocol infusion interval , monitor BP, and do not simultaneously start procainamide. If hypotension and poor perfusion develop, you stop the infusion mindset and move to synchronized cardioversion .

Scenario B — Unstable—do not hide behind drugs: A toddler with wide-complex tachycardia is limp and hypotensive with weak pulses. Drawing amiodarone is fine in parallel , but the first rhythm-specific therapy is synchronized cardioversion at 0.5–1 J/kg , not waiting for the infusion to finish.

Scenario C — Wrong drug class: A nurse suggests adenosine 0.1 mg/kg for irregular wide-complex tachycardia in an adolescent with possible WPW. You stop that plan: avoid adenosine in irregular wide / pre-excitation concerns; support ABCs, get expert help, and cardiovert if unstable.

Scenario D — Arrest vs pulse contrast: During CPR for refractory pVT, amiodarone may be given as an arrest bolus of 5 mg/kg . After ROSC, ongoing infusions and expert management differ from the code-bolus context—do not confuse the two on test items that carefully specify “with a pulse” vs “pulseless.”

Exam traps

Trap Correction
Rapid-pushing amiodarone like adenosine in a child with a pulse Perfusing VT → over time / infusion concept
Using adenosine as first-line for VT Wrong pathway—VT drugs or electricity
Stacking amiodarone + procainamide routinely Avoid casual combination; expert guidance
Choosing drugs before cardioversion in shock Unstable → electricity first

Forgetting 5 mg/kg as the amiodarone number Memorize 5 mg/kg across pulse and arrest contexts, but separate how it is given

Bottom line for 10.3: For tachycardia with a pulse , match the drug to the rhythm class: adenosine for appropriate narrow SVT , amiodarone 5 mg/kg over time (or procainamide/lidocaine alternatives) for perfusing VT , magnesium in torsades context, expert consultation , no casual stacking , and cardioversion first whenever cardiopulmonary compromise appears. Link Chapters 8–10: arrest boluses and defibrillation when pulseless; synchronized shocks and careful infusions when a pulse remains.