The use of the diving reflex supraventricular tachycardia
to terminate in a 2-week-old
infant
John Hamilton* Douglas Moodie, M.D. Jay Levy, M.D. Madison,
Wise.
Paroxysmal supraventricular tachycardia (PST) is a treatable cardiac emergency. Unfortunately, reflex vagal stimulation by carotid sinus and unilateral eyeball pressure, induction of vomiting, breath holding, or the Valsalva maneuver are rarely successful in terminating the tachycardia in children, particularly small infants. Other standard forms of therapy such as rapid intravenous digitalization and direct current countershock carry some significant risks. Stimulation of the diving reflex by immersion of the face in cold water has been noted to terminate attacks of supraventricular tachycardia in adults’-” and children.“. 4 There is one recent report of the use of the diving reflex to terminate PST in two infants.” We wish to report successful use of the diving reflex to terminate an attack of PST in a lkday-old infant and to emphasize the need for careful control of the temperature of the water bath used for facial immersion. Case report Patient J. D. is a I4-day-old female, the product of a full-term spontaneous vaginal delivery to a 33-year-old gravida 3 para 3 female who had no problems during pregnancy, labor, or delivery. The birth weight was 6 pounds, 11% ounces. The infant had been intermittently tachypneic from birth, but had fed well until 12 days of age when she became severely tachypneic and began vomiting. The next day she was brought From the Division Hospitals, Madison,
of Pediatric Wise.
Cardiology,
Received
for publication
Feb. 9, 1978.
Accepted
for publication
Feb. 28. 1978.
University
of Wisconsin
Reprint requests: Douglas S. Moodie, M.D., Division of Pediatric Cardiology, 117 Childrens Hospital, University of Wisconsin Hospitals, Madison, Wise. 53706. *Senior go, Ill.
medical
student,
0002-8703/79/030371
University
+ 04$00.40/O
of Illinois
Medical
0 1979 The
School,
Chica-
C. V. Mosby
Co.
to the University of Wisconsin Childrens Hospital where her admission electrocardiogram showed a supraventricular tachycardia with a rate of 300 (Fig. 1). She was noted to be in acute congestive heart failure with poor tissue perfusion. Carotid massage and unilateral eyeball pressure were not successful in terminating the tachycardia. Intraveneous digitalization (.9 mg./M.‘) was instituted with half the calculated total digitalizing dose given initially. Two minutes later the infant’s face was placed in a basin of ice water at 5” C. for 5 seconds. Her nostrils were manually occluded to prevent aspiration. The PST converted to a sinus rhythm of 120 within 3 seconds and within 5 seconds the rate was 150 (Fig. 2). She remained at this rate for 1% hours at which time PST recurred. Therapy, using the ice water bath at 5” C. was reinstituted. Sinus rhythm was restored immediately after facial immersion, but after 10 minutes, PST again developed. This lasted for 5 minutes, at which time she again converted to sinus rhythm without any further intervention. She was digitalized intraveneously over 24 hours and remained in sinus rhythm over the next 6 days with resolution of the congestive heart failure. At follow-up examination 2 months following discharge, the infant remains in sinus rhythm with a rate of 140 per minute. There is no evidence on physical examination, chest x-ray, or echocardiogram of underlying congenital heart disease. An ectopic atria1 pacemaker is noted on the electrocardiogram (Fig. 3).
Discussion
The rapid response of the three reported newborn infants with supraventricular tachycardia to the diving reflex makes this ideal therapy for distressed infants with this arrhythmia. The diving reflex has been discussed by several authors6-“l It is generally agreed that it is a vagally mediated response initiated by facial skin sensors and breathholding.‘, 9. lo The diving reflex causes peripheral vasoconstriction and a vagally mediated decrease in cardiac output and heart rate with stable or slightly increased blood pressure. This reflex, then, decreases blood supply to
American
Heart
Journal
3 7 1
Hamilton,
Moodie,
and
Levy
AVR
AVL
V4R
v4 v/2
Fig. 1. Twelve-lead electrocardiographic with a rate of 300. There are large
Fig. 2. Rhythm demonstrating
strip 5 seconds sinus rhythm with
following a heart
v6
tracing at time of admission demonstrating supraventricular posterior and inferior forces noted as well as increased anterior
facial immersion rate of 150.
viscera and muscles, but maintains effective blood supply to the brain and heart, enabling animals to remain submerged for long periods of time.6 In man, the diving reflex has been demonstrated at birth. The temperature of the bath used for immersion has been noted to be of importance.“. 8-11The vagal response becomes more profound when the temperature of the bath is reduced below 20” C. Hunt and associates,” however, felt that a temperature of 2 to 4 o C. was too low and obtained maximal results with a temperature of 18” C.” There have been reports of adults who developed ventricular tachycardia when the
372
AVF
tachycardia forces.
temperature in an ice bath was below 4’ C. after facial immersion for a period of 30 seconds. Perhaps the cold temperature and prolonged immersion resulted in a considerable catecholamine discharge which was responsible for ventricular dysrhythmias. In the three infants reported, the total time of each facial immersion was less than 6 seconds. In the previously reported cases of the use of the diving reflex in children, no mention is made of the temperature of the water bath.l, s The temperature of our bath was 5” C. and we noted no ventricular arrhythmias at that temperature. We have demonstrated the effectiveness of the diving reflex in treating PST in a 2-week-old infant. The use of the diving reflex is a valuable tool which can be used to convert PST in newborns, especially those with circulatory insufficiency. Careful attention must be paid to the temperature of the water bath to avoid causing ventricular dysrhythmias. Since the effect is
March,
1979,
Vol.
97,
No.
3
Diving
AVL
AVR
reflex to terminate
PST
AVF
V4R
v6 ‘/2
Fig.
heart
3. Twelve-lead electrocardiogram rate of 140. An ectopic atria1
short-lived, it is important of the tachyarrhythmia agent such as digitalis.
tracing pacemaker
2 months is noted.
to prevent recurrence with an appropriate
Summary
The use of the diving reflex to terminate a case of paroxysmal supraventricular tachycardia (PST) is described in a 2-week-old infant who presented in severe congestive heart failure with supraventricular tachycardia at a rate of 300. The infant’s face was placed in a basin of ice water at 5” C. for 5 seconds with manual occlusion of the
American
Heart
Journal
following
discharge
demonstrating
sinus
rhythm
with
a
infant’s nostrils to prevent aspiration. The PST converted to a sinus rhythm of 120 within 3 seconds of facial immersion. The physiology of the diving reflex is reviewed and the uses and hazards of this reflex in terminating attacks of PST in infants is discussed. REFERENCES
1.
2.
Wildenthal, K., Atkins, J., Leshin, S., and Skelton, C.L.: The diving reflex used to treat paroxysmal atria1 tachycardia, Lancet 1:12, 1975. Pickering, R., and Bolton-Maggs, P.: Treatment of supraventricular tachycardia, Lancet 1:340, 1975.
373
Hamilton,
3.
4.
5.
6. 7. 8.
Moodie,
and
Levy
Whayne, M.: Conversion of paroxysmal atria1 tachycardia by facial immersion in ice water, JACEP 5:434, 1976. Whitman, V., and Zakeosian, G.: The diving reflex in termination of supraventricular tachycardia in childhood, J. Pediatr. 89:1032, 1976. Whitman, V., Friedman, Z., Berman, W., and Maisels, M.J.: Supraventricular tachycardia in newborn infants: An approach to therapy, J. Pediatr. 90:304, 1977. Elsner, R.W., and Scholander, P.F.: Selective ischemia in diving man, AM. HEART J. 65:571,X)63. Brick, I.: Cirulatory response to immersing the face in water, J. Appl. Physiol. 2 1:33, 1966. Whayne, T.F., and Killip, T.: Diving bradycardia in man:
Information
9.
10.
11.
12.
Comparison of different stimuli and clinical application, Circulation 34 (Suppl. 3):238, 1966. Kawakami. Y., Natelson. B., and DuBois. A.B.: Cardiovascular effects of face immersion and factors affecting diving reflex in man, J. Appl. Physiol. 23:964, 1967. Kobayasi, S.. and Ogawa, T.: Effect of water temperature on bradycardia during nonapneic facial immersion in man, Jap. J. Physiol. 23:613, 1973. Hunt, N.G., Whitaker, D.K., and Willmott, N.J.: Water temperature and the “diving reflex,” Lancet 1:572, 1975. Condry, P., Jain, R., Marshall, R., and Bowyer. A.: Ventricular tachycardia caused by the diving reflex, Lancet 2:1263, 1975.
for authors
Most of the provisions of the Copyright Act of 1976 became effective on January 1, 1978. Therefore, all manuscripts must be accompanied by the following written statement, signed by one author: “The undersigned author transfers all copyright ownership of the manuscript (title of article) to The C. V. Mosby Company in the event the work is published. The undersigned author warrants that the article is original, is not under consideration by another journal, and has not been previously published. I sign for and accept responsibility for releasing this material on behalf of any and all co-authors.” Authors will be consulted, when possible, regarding republication of their material.
374
March,
1979,
Vol.
97.
NO. 3
to terminate in a 2-week-old
infant
John Hamilton* Douglas Moodie, M.D. Jay Levy, M.D. Madison,
Wise.
Paroxysmal supraventricular tachycardia (PST) is a treatable cardiac emergency. Unfortunately, reflex vagal stimulation by carotid sinus and unilateral eyeball pressure, induction of vomiting, breath holding, or the Valsalva maneuver are rarely successful in terminating the tachycardia in children, particularly small infants. Other standard forms of therapy such as rapid intravenous digitalization and direct current countershock carry some significant risks. Stimulation of the diving reflex by immersion of the face in cold water has been noted to terminate attacks of supraventricular tachycardia in adults’-” and children.“. 4 There is one recent report of the use of the diving reflex to terminate PST in two infants.” We wish to report successful use of the diving reflex to terminate an attack of PST in a lkday-old infant and to emphasize the need for careful control of the temperature of the water bath used for facial immersion. Case report Patient J. D. is a I4-day-old female, the product of a full-term spontaneous vaginal delivery to a 33-year-old gravida 3 para 3 female who had no problems during pregnancy, labor, or delivery. The birth weight was 6 pounds, 11% ounces. The infant had been intermittently tachypneic from birth, but had fed well until 12 days of age when she became severely tachypneic and began vomiting. The next day she was brought From the Division Hospitals, Madison,
of Pediatric Wise.
Cardiology,
Received
for publication
Feb. 9, 1978.
Accepted
for publication
Feb. 28. 1978.
University
of Wisconsin
Reprint requests: Douglas S. Moodie, M.D., Division of Pediatric Cardiology, 117 Childrens Hospital, University of Wisconsin Hospitals, Madison, Wise. 53706. *Senior go, Ill.
medical
student,
0002-8703/79/030371
University
+ 04$00.40/O
of Illinois
Medical
0 1979 The
School,
Chica-
C. V. Mosby
Co.
to the University of Wisconsin Childrens Hospital where her admission electrocardiogram showed a supraventricular tachycardia with a rate of 300 (Fig. 1). She was noted to be in acute congestive heart failure with poor tissue perfusion. Carotid massage and unilateral eyeball pressure were not successful in terminating the tachycardia. Intraveneous digitalization (.9 mg./M.‘) was instituted with half the calculated total digitalizing dose given initially. Two minutes later the infant’s face was placed in a basin of ice water at 5” C. for 5 seconds. Her nostrils were manually occluded to prevent aspiration. The PST converted to a sinus rhythm of 120 within 3 seconds and within 5 seconds the rate was 150 (Fig. 2). She remained at this rate for 1% hours at which time PST recurred. Therapy, using the ice water bath at 5” C. was reinstituted. Sinus rhythm was restored immediately after facial immersion, but after 10 minutes, PST again developed. This lasted for 5 minutes, at which time she again converted to sinus rhythm without any further intervention. She was digitalized intraveneously over 24 hours and remained in sinus rhythm over the next 6 days with resolution of the congestive heart failure. At follow-up examination 2 months following discharge, the infant remains in sinus rhythm with a rate of 140 per minute. There is no evidence on physical examination, chest x-ray, or echocardiogram of underlying congenital heart disease. An ectopic atria1 pacemaker is noted on the electrocardiogram (Fig. 3).
Discussion
The rapid response of the three reported newborn infants with supraventricular tachycardia to the diving reflex makes this ideal therapy for distressed infants with this arrhythmia. The diving reflex has been discussed by several authors6-“l It is generally agreed that it is a vagally mediated response initiated by facial skin sensors and breathholding.‘, 9. lo The diving reflex causes peripheral vasoconstriction and a vagally mediated decrease in cardiac output and heart rate with stable or slightly increased blood pressure. This reflex, then, decreases blood supply to
American
Heart
Journal
3 7 1
Hamilton,
Moodie,
and
Levy
AVR
AVL
V4R
v4 v/2
Fig. 1. Twelve-lead electrocardiographic with a rate of 300. There are large
Fig. 2. Rhythm demonstrating
strip 5 seconds sinus rhythm with
following a heart
v6
tracing at time of admission demonstrating supraventricular posterior and inferior forces noted as well as increased anterior
facial immersion rate of 150.
viscera and muscles, but maintains effective blood supply to the brain and heart, enabling animals to remain submerged for long periods of time.6 In man, the diving reflex has been demonstrated at birth. The temperature of the bath used for immersion has been noted to be of importance.“. 8-11The vagal response becomes more profound when the temperature of the bath is reduced below 20” C. Hunt and associates,” however, felt that a temperature of 2 to 4 o C. was too low and obtained maximal results with a temperature of 18” C.” There have been reports of adults who developed ventricular tachycardia when the
372
AVF
tachycardia forces.
temperature in an ice bath was below 4’ C. after facial immersion for a period of 30 seconds. Perhaps the cold temperature and prolonged immersion resulted in a considerable catecholamine discharge which was responsible for ventricular dysrhythmias. In the three infants reported, the total time of each facial immersion was less than 6 seconds. In the previously reported cases of the use of the diving reflex in children, no mention is made of the temperature of the water bath.l, s The temperature of our bath was 5” C. and we noted no ventricular arrhythmias at that temperature. We have demonstrated the effectiveness of the diving reflex in treating PST in a 2-week-old infant. The use of the diving reflex is a valuable tool which can be used to convert PST in newborns, especially those with circulatory insufficiency. Careful attention must be paid to the temperature of the water bath to avoid causing ventricular dysrhythmias. Since the effect is
March,
1979,
Vol.
97,
No.
3
Diving
AVL
AVR
reflex to terminate
PST
AVF
V4R
v6 ‘/2
Fig.
heart
3. Twelve-lead electrocardiogram rate of 140. An ectopic atria1
short-lived, it is important of the tachyarrhythmia agent such as digitalis.
tracing pacemaker
2 months is noted.
to prevent recurrence with an appropriate
Summary
The use of the diving reflex to terminate a case of paroxysmal supraventricular tachycardia (PST) is described in a 2-week-old infant who presented in severe congestive heart failure with supraventricular tachycardia at a rate of 300. The infant’s face was placed in a basin of ice water at 5” C. for 5 seconds with manual occlusion of the
American
Heart
Journal
following
discharge
demonstrating
sinus
rhythm
with
a
infant’s nostrils to prevent aspiration. The PST converted to a sinus rhythm of 120 within 3 seconds of facial immersion. The physiology of the diving reflex is reviewed and the uses and hazards of this reflex in terminating attacks of PST in infants is discussed. REFERENCES
1.
2.
Wildenthal, K., Atkins, J., Leshin, S., and Skelton, C.L.: The diving reflex used to treat paroxysmal atria1 tachycardia, Lancet 1:12, 1975. Pickering, R., and Bolton-Maggs, P.: Treatment of supraventricular tachycardia, Lancet 1:340, 1975.
373
Hamilton,
3.
4.
5.
6. 7. 8.
Moodie,
and
Levy
Whayne, M.: Conversion of paroxysmal atria1 tachycardia by facial immersion in ice water, JACEP 5:434, 1976. Whitman, V., and Zakeosian, G.: The diving reflex in termination of supraventricular tachycardia in childhood, J. Pediatr. 89:1032, 1976. Whitman, V., Friedman, Z., Berman, W., and Maisels, M.J.: Supraventricular tachycardia in newborn infants: An approach to therapy, J. Pediatr. 90:304, 1977. Elsner, R.W., and Scholander, P.F.: Selective ischemia in diving man, AM. HEART J. 65:571,X)63. Brick, I.: Cirulatory response to immersing the face in water, J. Appl. Physiol. 2 1:33, 1966. Whayne, T.F., and Killip, T.: Diving bradycardia in man:
Information
9.
10.
11.
12.
Comparison of different stimuli and clinical application, Circulation 34 (Suppl. 3):238, 1966. Kawakami. Y., Natelson. B., and DuBois. A.B.: Cardiovascular effects of face immersion and factors affecting diving reflex in man, J. Appl. Physiol. 23:964, 1967. Kobayasi, S.. and Ogawa, T.: Effect of water temperature on bradycardia during nonapneic facial immersion in man, Jap. J. Physiol. 23:613, 1973. Hunt, N.G., Whitaker, D.K., and Willmott, N.J.: Water temperature and the “diving reflex,” Lancet 1:572, 1975. Condry, P., Jain, R., Marshall, R., and Bowyer. A.: Ventricular tachycardia caused by the diving reflex, Lancet 2:1263, 1975.
for authors
Most of the provisions of the Copyright Act of 1976 became effective on January 1, 1978. Therefore, all manuscripts must be accompanied by the following written statement, signed by one author: “The undersigned author transfers all copyright ownership of the manuscript (title of article) to The C. V. Mosby Company in the event the work is published. The undersigned author warrants that the article is original, is not under consideration by another journal, and has not been previously published. I sign for and accept responsibility for releasing this material on behalf of any and all co-authors.” Authors will be consulted, when possible, regarding republication of their material.
374
March,
1979,
Vol.
97.
NO. 3
