Principles of ECG Diagnosis

9
Pediatric electrocardiography
Dr Ghazi Ahmad Radaideh
MD, FRCP
Rashid Hospital
Dubai - UAE
16/12/2008

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Reading 12-Lead ECG step-by-step

(RAWIHI)
1. Rate, Rhythm and Regularity
2. Determine the QRS Axis
3. Evaluate the Waves (P,QRS,T ),
Intervals (PR,ST,QT)
4. Evaluate for chamber Hypertrophy
5. Look for myocardial Infarction and Ischemia
6. Interpret the ECG
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Introduction
The basic principles of cardiac conduction and
depolarisation in infants and children are the
same as for adults,
Age related changes in the anatomy and
physiology of infants and children produce
normal ranges for ECG features that differ from
adults and vary with age.
Awareness of these differences is the key to correct
interpretation of pediatric ECG
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Indications for paediatric ECG

Syncope or seizure
Exertional
symptoms
Drug ingestion
Tachyarrhythmia
Bradyarrhythmia

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Cyanotic episodes
Heart failure

Hypothermia

Electrolyte disturbance
Kawasaki disease
Rheumatic fever
Myocarditis
Myocardial contusion
Pericarditis
Post cardiac surgery
Congenital heart defects

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Paediatric electrocardiographic
findings that may be normal

Heart rate >100 beats/min

QRS axis >90
Right precordial T wave inversion
Dominant right precordial R waves

Short PR and QT intervals

Short P wave and short duration of QRS complexes
Inferior and lateral Q waves

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 right axis deviation,

dominant R wave in leads V1,
Right precordial T wave inversion
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Age related changes in normal ECG

Right and Left Ventricles:
At birth the RV is larger than the LV.
the LV increasing in size until it is larger than
the RV by age 1 month.
By age 6 months, the ratio of the RV to the LV
is similar to that of an adult.

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Age related changes in normal ECG

Mean and ranges of Normal QRS Axes

The axis changes gradually from Rt axis to normal

Age
1 wk-1mo
1-3mo
3mo-3yr
Older than 3yr
Adults
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Range
+110 (+30 to +180)
+70 (+10 to +125)
+60 (+10 to +110)
+60 (+20 to +120)
+50 (-30 to +105
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Age related changes in normal ECG

The PR interval decreases from birth to age
1 year and then gradually increases
throughout childhood.
The P wave duration and the QRS duration
increase with age.
The QT interval depends on heart rate and
age, increasing with age while decreasing
with heart rate.
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P wave amplitude and duration:

Mean P amplitude:
Normal P wave duration:
Max. P wave duration;

1.5mm, max. 3mm.

0.06 0.02s.
< 1 year
Child

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0.08sec
0.10sec

PR interval varies with age and heart rate

Age
< 3 yr.
3 - 16 yr.
> 16 yr.

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Lower limit
0.08sec
0.10sec
0.12sec

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Upper limit
0.15
(HR < 100)
0.16
(HR < 100)
0.18
(HR < 100)

QRS duration

Age
Premature infants
Full term
1 - 3 yr.
Child > 3 yr
Adult

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Range
0.04sec
0.05sec
0.06sec
0.07sec
0.08sec

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T wave
Upright T waves in V1-V3 are normal in the
neonate up to 7 days.
The T wave in lead V1 inverts by 7 days
and typically remains inverted until at least
age 7 years.
Upright T waves in the right precordial leads
(V1 to V3) between ages 7 days and 7 years are
a potentially important abnormality and usually
indicate RVH.
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Heart Rate
The resting heart rate decreases with age
from about:

140 beats/min
120 beats/min
100
adult values

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at birth to
at age 1 year, to
at 5 years, to
by 10 years.

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Normal values in pediatric ECG

Age

PR interval
(ms)

R wave (S wave)
QRS duration amplitude (mm)
(ms)
Lead V1

R wave (S wave)
amplitude (mm)
Lead V6

Birth

80-160

<75

5-26 (1-23)

0-12 (0-10)

6 months

70-150

<75

3-20 (1-17)

6-22 (0-10)

1 year

70-150

<75

2-20 (1-20)

6-23 (0-7)

5 years

80-160

<80

1-16 (2-22)

8-25 (0-5)

10 years

90-170

<85

1-12 (3-25)

9-26 (0-4)

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Prolongation of the QRS complex

Wide QRS complex may be due to:
bundle branch block,
ventricular hypertrophy,
metabolic disturbances, or drugs

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Criteria for RVH

A qR complex or an rSR' pattern in lead V1,
upright T waves in the right precordial leads
between ages 7 days and 7 years,
marked right axis deviation (particularly
associated with right atrial enlargement),
complete reversal of the adult precordial pattern
of R and S waves
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Criteria for RVH

RV1
SV6

> 20mm at all ages

> 14mm (0-7days); > 10mm (1wk-6mth);
> 7mm (6mth-1yr); > 5mm (>1yr)

R/S V1

6.5 (0-3mth); 4.0 (3-6mth);

2.4 (6mth-3yr); 1.6 (3-5yr); 0.8 (6-15yr)

T wave upright in V4R or V1 after 72 hrs.

Presence of Q wave in V1

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RVH in the newborn

S waves in lead I, 12mm
R waves in aVR, 8mm
Important abnormalities in V1 such as:
Pure R waves (without S) in V1, 10mm
R waves in V1, 25mm
QR pattern in V1 (also seen in 10% of normal
newborns)
Upright T waves in V1 in newborns > 7days old

QRS axis greater than +180

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LVH
Left ventricular hypertrophy may be indicated
by:
deep Q waves in the left precordial leads or the
typical adult changes of lateral ST depression and
T wave inversion

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Criteria for LVH

SV1 > 20mm
RV6 > 20mm > 26mm in older child
SV1 + RV6 > 40mm over 1yr of age;
> 30mm if < 1yr
Q wave of 4mm or more in V 5-6
T wave inversion in V 5-6

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The QT interval
Approach to QT interval in children is the same as in
adults except for the fact that it is highly variable in
the first three days of life)
QT prolongation may be seen in association with:
hypokalaemia, hypocalcaemia, hypothermia, drug treatment,
cerebral injury, and the congenital long QT syndrome.

Other features of the long QT syndrome include:

notching of the T waves, abnormal U waves, relative
bradycardia for age, and T wave alternans.

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T waves
T waves may be inverted OR or biphasic in strain
pattern due to ventricular hypertrophy,
T waves may be inverted as a result of myocardial
disease (inflammation, infarction, or contusion).
Flat T waves are seen in association with
hypothyroidism. Abnormally tall T waves occur
with hyperkalaemia.

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Abnormalities of rate and rhythm

The wide variation in children's heart rate with age
and activity.
Systemic illness must be considered in any child presenting
with an abnormal HR or Rhythm.
Sinus tachycardia in babies and infants can result in rates of
up to 240 beats/min,
hypoxia, sepsis, acidosis, or intracranial lesions may cause
bradycardia.
Sinus arrhythmia is a common feature .
Its relation to breathing slowing on expiration and speeding up on
inspiration allows diagnosis.
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Electrocardiogram from 9 year old boy

marked sinus arrhythmia

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Tachyarrhythmias
The approach to ECG diagnosis of
tachyarrhythmias in children follows the same
principles as for adults,
Most narrow complex tachycardias in children are due to
(AVRT) secondary to an accessory pathway.
(AVNRT) is rare in infants but may be seen in later
childhood and adolescence.
Atrial flutter and fibrillation are rare in childhood and are
usually associated with underlying structural heart disease or
previous cardiac surgery.
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Extrasystoles
Atrial extrasystoles are very common and
rarely associated with disease
Ventricular extrasystoles are also common
and, are almost always benign, in the
context of the structurally normal heart
Typically, atrial and ventricular extrasystoles
are abolished by exercise

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Ventricular Tachycardia
Although all forms of ventricular tachycardia are
rare, broad complex tachycardia should be
considered to be ventricular tachycardia until
proved otherwise.
Monomorphic ventricular tachycardia may occur
secondary to surgery for congenital heart disease.
Polymorphic ventricular tachycardia, or torsades de
pointes, is associated with the long QT syndrome

Bundle branch block (usually right bundle) often

occurs after cardiac surgery, and a previous
electrocardiogram can be helpful.
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ECG from 6 year old girl with congenital

heart block secondary to maternal
antiphospholipid antibodies;

there is complete atrioventricular

dissociation, and the ventricular escape rate
is about 50 beats/min

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