Tachycardia with a pulse (PALS)

Paediatric emergency management · Cardiology · Emergency

Assess perfusion and QRS width on the monitor. Support ABC, give oxygen, obtain access, and get a 12-lead ECG if it will not delay treatment.

Narrow QRS (0.09 s or less)

Sinus tachycardia — P waves present, variable R–R, rate usually under 220 (infant) or 180 (child); treat the cause (fever, pain, hypovolaemia).
SVT — absent or abnormal P waves, no beat-to-beat variability, rate usually 220 or more (infant) or 180 or more (child).

SVT with poor perfusion

Vagal manoeuvres (ice to the face) only if they will not delay treatment.

Adenosine IV/IO (1st dose)0.1 mg/kg rapid push (max 6 mg) with an immediate flushMaximum 6 mg

Adenosine IV/IO (2nd dose)0.2 mg/kg (max 12 mg) if no responseMaximum 12 mg

Synchronised cardioversion0.5–1 J/kg; increase to 2 J/kg if ineffective. Sedate if possible, do not delay.Maximum 100 J

Wide QRS (over 0.09 s)

Assume VT. With poor perfusion → synchronised cardioversion 0.5–1 J/kg (then 2 J/kg).
Adenosine only if the rhythm is regular and the QRS monomorphic.
Amiodarone 5 mg/kg or procainamide 15 mg/kg (do not combine) with expert consultation.

Common questions

What is the first step in tachycardia with a pulse (pals)?

Assess perfusion and QRS width on the monitor. Support ABC, give oxygen, obtain access, and get a 12-lead ECG if it will not delay treatment.

What drug doses are used in tachycardia with a pulse (pals)?

Adenosine IV/IO (1st dose): 0.1 mg/kg rapid push (max 6 mg) with an immediate flush. Adenosine IV/IO (2nd dose): 0.2 mg/kg (max 12 mg) if no response. Synchronised cardioversion: 0.5–1 J/kg; increase to 2 J/kg if ineffective. Sedate if possible, do not delay..

About this page

Compiled from standard paediatric references. Verify against a current formulary and your local protocol.

Spotted something wrong? Report an error on this page — corrections from clinicians are welcome and are reviewed before any change is published.

Last reviewed 2026-08-12.