Recognition and treatment of unstable supraventricular tachycardia by pediatric residents in a simulation scenario.

INTRODUCTION: Supraventricular tachycardia (SVT) is the most frequent tachydysrhythmia in children. SVT with hemodynamic compromise should be terminated by immediate electrical cardioversion. Study objectives were to: (1) establish time to recognition and cardioversion of simulated unstable SVT; and (2) document delays and mistakes made during cardioversion.
METHODS: Ten teams of pediatric residents were presented with an unresponsive "patient" (Laerdal SimMan) in unstable SVT. Actions of team members and simulator timestamps of key events were recorded. A retrospective review of events and time logs was performed with primary outcome measure of time to successful cardioversion.
RESULTS: Median time to cardioversion was 8.9 minutes (range, 5.3 minutes to unsuccessful scenario terminated at 15 minutes). In 20% of scenarios, the patient was never cardioverted. Ninety percent of teams administered adenosine, but 44% of attempts demonstrated incorrect administration technique. Other maneuvers before cardioversion: 70% administered fluid, 60% attempted vagal maneuvers, 30% requested electrocardiogram, 30% requested antiarrhythmics. In 20% of scenarios, the rhythm was misidentified. When cardioversion was performed, 25% failed to use gel, 37.5% failed to synchronize, 25% used inappropriate energy doses. In 60% of scenarios, no oxygen was administered. In 90% there was no assignment of Glasgow Coma Scale, and no assessment of mental status in 30%. In 60% perfusion was not assessed.
CONCLUSIONS: Median time to cardioversion of 8.9 minutes is inconsistent with AHA recommendations for treatment of unstable SVT with "immediate cardioversion." Delays were secondary to lack of recognition of "unstable" SVT, due to failure to assess perfusion and mental status. Errors encountered during simulation identify curriculum reform targets.