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PEDIATRIC ECGs

OBJECTIVES

1. Review Pediatric ECG


Indications
2. Discuss some similarities
and differences between
Pediatric and Adult ECGs
3. Discuss pediatric
arrhythmias
Successful use of
Pediatric
Electrocardiography
Beaware of age related differences in
ECG indications

Know N ranges for ECG variables

Recognize typical differences in


infants/children
 Syncope/seizure  Electrolyte disturbance
 Exertional symptoms  Kawasaki disease
 Drug ingestions  Rheumatic fever
 Tachyarrhythmia  Myocarditis
 Bradyarrhythmia  Myocardial contusion
 Cyanotic episodes
 Pericarditis
 Heart Failure
 Post cardiac surgery
 Hypothermia
 Congenital heart defects

Indications for a Pediatric ECG


“PAEDS ECG” + 2 Fs
P- pericarditis (or E-electrolyte
myocarditis), post disturbance
cardiac surgery C-cyanosis, contusion
A-arrhythmias (tachy or (myocardial), cold
bradyarrhythmia) (hypothermia)
E-exertional symptoms G- conGenital heart
D-drugs, disease defects
(Kawasaki)
2 Fs:
S-syncope/seizure
◦ Fever (rheumatic)
◦ Failure (heart)
Rarely cardiac in origin

ECG NOT usually helpful in diagnosis

Consider ECG for parent reassurance

Chest Pain in Kids


ECG Recording
Distract child
Limb electrodes proximal, less movement
artifact
Standard adult positions, but add V3R or
V4R to detect right ventricular or atrial
hypertrophy
Standard paper speed (25 mm/s) and
deflection (10 mm/mV)
AGE RELATED CHANGES
IN NORMAL ECGs
The famous 1 complex, 2
segments, 2 intervals and 5
waves.
Heart development during infancy and
childhood causes differences in HR,
interval durations, and ventricular
dominance

Abnormal adult ECG features may be


Normal age-related changes in pediatrics
Pediatric ECG findings
that may be Normal
HR > 100 bpm
Right precordial T wave inversion
Dominant RPLs R waves
Short PR and QT intervals
Short P wave and short QRS duration
Inferior and lateral Q waves
Approach in reading
Paediatric ECG
Heart Rate
CO = SV X HR
Higher rate for infant’s high metabolic
needs, small ventricle size cannot
compensate by increasing SV (newborn
commonly 120-160 bpm)
As heart grows, SV increases. Higher
rate no longer needed to produce
adequate CO
Rate gradually declines with age
RESTING HR
Birth 140 bpm

1 yr: 120 bpm

5 yr: 100 bpm

10 yr: adult values


Amplitude varies little with age
Best evaluated in II, V1, or V4R
Wide P waves: L atrial hypertrophy
Tall P waves (> 2.5 mm) in II: R atrial
hypertrophy
Abnormal P patterns (ie inversion in II or
aVF): atrial activation from site other than
sinoatrial node

P wave
P axis in range 0 to +90°
P waves upright in I, II & aVF
P wave duration 0.06s +/- 0.02s in children
Max P duration 0.1s in children & 0.08s in
infants.
E.g if P axis is in range of +90 to + 180º what
would u suspect in a normal healthy child?

P wave
P wave + physiologic delay in AV node
(PQ segment)
Varies with age & HR.
Age increases, HR decreases & PR interval
increases in duration
With the exception the PR interval is
longer in duration at Birth than at infants
period

PR Interval
PR Interval

Decreases from AGE PR (ms)


birth-1 yr, then
Birth 80-160
gradually increases
t/o childhood 6m 70-150

1 yr 70-150

5 yr 80-160

10 yr 90-170
Ventricle Dominance
Fetal heart pumps blood to high resistance
pulmonary circuit, so RV pressure high
After birth:
◦ Pulmonary vascular resistance falls
◦ RV muscularity recedes
◦ RV contribution to ECG diminishes
Systemic vascular resistance changes:
increased LV size until > than RV (1 month)
6 months: RV/LV ratio similar to adults
Shift from newborn RV dominance to LV
dominance by 1 yr
 RV dominance: R wave is larger than S wave
in V1
Heart Changes
LV/RV Weight Ratio

30 weeks gestation 1.2 : 1


Neonates: RV 33 weeks gestation 1.0 : 1
larger than LV, so
36 weeks gestation 0.8 : 1
Normal to have:
◦ Right axis deviation At birth 0.8 : 1
◦ Large precordial R 1 month 1.5 : 1
waves
6months 2.0 : 1
◦ Upright T waves
Alduts 2.5 : 1
D3oL baby
RAD
Dominant R
in V4R/V1
Upright T in
V1
Upright T
persistence
in RPLs > 1st
wk: sign of
RVH
12 year old
ECG
Normal adult
axis
R wave no
longer
dominant in R
precordial
leads
QRS axis
 Mean vector of Vent Newborn +125°
Depolarization process
 Birth:
1 month +90°
◦ mean QRS axis +125° with
RAD
◦ up to 180° can be normal in 3 years +60°
newborn
◦ R waves prominent in R
precordium adult +50°
◦ S waves prominent in L
precordium
 Axis moves to Left as child
ages
QRS
 Ventricular AGE QRS
Depolarizati duration
on time (ms)
 QRS
duration are Birth < 75
short in the 6m < 75
young infant
& increases 1 yr < 75
with age.
5 yr < 80
10 yr < 85
Normal values in paediatric
electrocardiograms
R wave (S Wave) Amplitude
(mm)
Age PR QRS duration Lead V1 Lead V6
Interval (ms) (ms)

Birth 80­160 < 75 5­26(1­23) 0­12 (0­10)

6 months 70­150 < 75 3­20 (1­17) 6­22 (0­10)

1 year 70­150 < 75 2­20 (1­20) 6­23 (0­7)

5 years 80­160 < 80 1­16 (2­22) 8­25 (0­5)

10 years 90­170 < 85 1­12 (3­25) 9­26 (0­4)


Q waves
Depolarization of Ventricular Septum
Commonly in I,II,III & aVF
Almost always in V5 & V6 but absent in
V4R & V1
Duration is 0.02s & not > 0.03s
In aVF & V5, max amplitude <6mm
In V6, should be <5mm
R/S Progression
In patient > 3 years of age
Progressive increase in R wave amplitude
toward V5
Progressive decrease in S wave amplitude
toward V6
1st month of life, complete reversal of R/S
progression
Btw 1mont & 3 years, partial reversal
present with dominant R in V1 as well as in
V5 & V6
T waves
Ventricular repolarization
T axis is more anterior with upright T
wave in V1
T wave in V1 inverts (Posterior) by 7 days,
stays inverted until 5 to 7 years then
progressively more anterior in later years
Upright T waves in right precordial leads
(V1-V3) between 7d and 7yrs are
ABNORMAL, usually RVH
QT interval
Varies with HR but not age, except in infancy
Must interpreted by Bazett’s formula QTc
Important in recognition of congenital
prolonged QT syndrome, and medication
effects (ie hyperK+, hypoCa++, dig, quinidine,
procainaminde, Li+, tricyclics, phenothiazides)
QTc should not exceed 0.44, except in infant
where QTc of up to 0.49s may be normal for
the 1st 6months of life.
 (if can’t calculate, shouldn’t be > half R-R
distance)
Occur at the end of T wave
Should not be included in QTc
Represents the repolarization of Purkinje
fibers
Present in hypokalemia

U wave
Long QT syndrome in 3 yr old
ABNORMAL
PAEDIATRIC ECGs
Ventricular Hypertrophy
 “Voltage Criteria”: Depend on age adjusted
values for R and S wave amplitudes
R wave (S wave) R wave (S wave)
amplitude (mm) amplitude (mm)

AGE V1 V6
Birth 5-26 (1-23) 0-12 (0-10)
6m 3-20 (1-17) 6-22 (0-10)
1 yr 2-20 (1-20) 6-23 (0-7)
5 yr 1-16 (2-22) 8-25 (0-5)
10 yr 1-12 (3-25) 9-26 (0-4)
RVH

Useful ECG Features


◦ qR or rSR’ in V1
◦ Upright T in RPLs: 7d-7yrs

◦ Marked right axis deviation (esp if with right


atrial enlargement)

◦ Complete reversal of adult precordial pattern


of R and S waves
Pediatric RVH
 13 yr old
 Transposition of
great arteries,
previous Mustard’s

 RV systemic
ventricle: RVH
 RAD
 Dominant R in R
precordial leads
Case: 6 m old with Cyanotic Episodes:
ToF and RVH

 Tall R in
V1,
reciprocal
S in V6
 qR in V3R
and V4R
 RAD 120*
 Upright T
V1-V3
(should be
inverted)
LVH
Useful ECG Features
◦ Deep Qs in L precordial leads
◦ Lateral ST depression and T wave inversion
Some Congenital Heart
Defects and ECG
Manifestations
 Anomalous L coronary  Aortic Stenosis
artery ◦ LVH
◦ Anterolat MI
 Anomalous  Coarctation
pulm
venous return ◦ < 6m: RBBB or RVH
◦ Total: RAD, RVH, RAH ◦ > 6m: LVH, N, RBBB
◦ Partial RVH or RBBB  Patentductus
arteriosus
◦ Small shunt: N
◦ Mod: LVH, +/- LAH
◦ Large: CVH, LAH
Some Congenital Heart
Defects and ECG
Manifestations
 Persistent truncus Transposition
arteriosus ◦ Intact septum: RVH,
◦ LVH or CVH RAH
 Pulmatresia (and ◦ VSD and/or PS: CVH,
hypoplastic RV) RAH, or CAH
◦ LVH Corrected
 Tetralogy of Fallot transposition
◦ RAD, RVH, +/- RAH ◦ AV blocks, WPW, LAH
or CAH, absent Q in
V5/V6, and qR in V1
ABNORMALITIES OF
RATE AND RHYTHM
Abnormal HR

Consider systemic illness in any child


with an abnormal HR

Sinus tachycardia in babies and infants


can be up to 240 bpm

Bradycardia: consider hypoxia, sepsis,


acidosis, intracranial lesions
Pediatric Arrhythmias
Any adult arrhythmia can occur in peds

Major difference in pediatric ECGs is


type of abN rhythms usually seen
Most common pediatric dysrhythmias:
SVT, bradycardia, and sinus arrhythmia

AF, atrial flutter, VT, or VF rare


BUT: kids with congenital heart
disease may have any arrhythmia
What should be done about
this ECG?
Nothing!

Sinus arrhythmia common in children’s


ECGs
Often quite marked
Sinus Arrhythmia

 Inspiration: increased blood flow to heart


decreases vagal tone: increased HR
 Expiration: increased vagal tone: lower HR
 Marked in asthma, upper airway obstruction,
increased ICP, and premature infants (immature
autonomic innervation)
 Must differentiate from AF
 Rarely in infants but N in many kids/athletes,
normally insignificant
Sinus Bradycardia

Sinusrate below N for age: 80 in


newborn is sinus brady; 50 in athletic
teenager is N

Common in severe distress:


hypoxia*/drugs

Can be asymptomatic/insignificant (ie


sleep/well-conditioned), treat if signs of
poor systemic perfusion
SVT
 Most common paeds arrhythmia
 Can occur in healthy infants and children
 Different
from sinus tach by unusually fast rate
and patient presentation:
◦ ST usually physiologic: fear, fever,
hypovolemia
◦ SVT: vague hx, child irritable, lethargic,
feeding poorly, may present with signs of CHF

 Regular rhythm > 220 (infants up to 280-320)


AV Blocks
Uncommon: atrial enlargement, surgical
damage to AV nodal tissue, or congenital
Same classification as adults

1stdegree AV block: must account for PR


change with age. Can be N, or occur in
rheumatic carditis, diphtheria, digoxin OD, and
congenital heart defects
Other Arrhythmias
AF/flutter: rare in children
Flutter: rheumatic heart dz, congenital
defects, cardiac surgery, in utero, or N
neonates
VT: RARE, extremely abN: monomorphic
associated with heart surgery; polymorphic
(torsades) with long QT syndrome
Aids to diagnose tachycardias (ie AV
dissociation and capture/fusion beats) LESS
common in kids
Other Arrhythmias
Atrial
and Ventricular extrasystoles very
common, usu benign if structurally N heart

VF: RARE, only ~ 10% of terminal rhythm;


congenital heart dz, prolonged resuscitation
efforts, prolonged QT or long QT syndrome

Asystole: common, least successfully resolved


lethal peds arrhythmia; hypoxia and acidosis
damage myocardium beyond repair
1. Indications for Pediatric ECGs
2. Some differences between Pediatric
and Adult ECGs
3. Common pediatric arrhythmias

What I Hope We Covered…


What You Should TRY to
Remember…
Kids ‘n’ Adults

SIMILARITIES DIFFERENCES
 Conduction  Kids:fast HR that
pathways
same, so waveforms slows with age,
(P, QRS, T) same, and shorter N intervals
that prolong with
waveform timing age, and diminution
measured the same of RV dominance
(i.e., PR, QRS, QT
interval)  Sinusbradycardia,
sinus arrhythmia
 Identical
approach to and SVT most
ECG analysis common
arrhythmias in kids
Findings that may be N
HR > 100 bpm
Right precordial T wave inversion
Dominant R precordial R waves
Short PR and QT intervals
Short P wave and short QRS duration
Inferior and lateral Q waves
REFERENCES
 ABC of clinical electrocardiograpy. Paediatric
electrocardiography. Goodacre S, McLeod K. BMJ Volume
324. June 8, 2002. Pgs 1382-1385
 ECG INTERPRETATION: WHAT IS DIFFERENT IN CHILDREN?
Mowery, Bernice, Suddaby, Elizabeth C., Pediatric Nursing,
0097-9805, May 1, 2001, Vol. 27, Issue 3.
 How to interpret Paediatric ECG by Gunneroth