Pediatrics 415394.A 3-month-old boy is brought to the ED by his mother because of
decreased feeding over the last 24 hours. The patient has been doing well
without any prior medical problems until today when the mother noted
sweating and irritability, particularly with feeding. In the ED, the patient
attempts to feed but within minutes stops and begins to cry. Vital signs
include a pulse of 240 beats per minute, RR of 50 breaths per minute, tem-
perature of 98.2°F, and pulse oximetry of 98% on room air. On physical
examination, the patient is pale and clammy to touch. Breath sounds are
clear on auscultation. Pulses are normal and symmetric in all extremities.
An ECG is seen below. Which of the following is the most appropriate next
step in management?
a. Synchronized cardioversion at 0.5 J/kg
b. Verapamil 0.1 mg/kg bolus
c. Defibrillation at 2 J/kg
d. Adenosine at 0.1 mg/kg followed by 0.2 mg/kg if first dose is ineffective
e. Carotid massage
(Reproduced, with permission, from Shah BR, Lucchesi M.Atlas of Pediatric Emergency
Medicine.New York, NY: McGraw-Hill; 2006: Figure 5-10.)