JURNAL DIVISION : CARDIOLOGY

PREDICTORS OF ABNORMAL
ELECTROCARDIOGRAMS IN THE
PEDIATRIC
EMERGENCY DEPARTMENT

Maya Susanti Shiv Gandhi, Miranda Lin, Sharon R Smith, Jesse J Sturm
 ABSTRACT
Background: Electrocardiograms (ECGs) are ordered in the pediatric emergency room for a wide variety
of chief complaints
Objectives : Criteria are lacking as to when physicians should obtain ECGs. This study uses a
large retrospective cohort of 880 pediatric emergency department (ED) patients to
highlight objective criteria including significant medical history and specific vital sign
abnormalities to guide clinicians as to which patients might have an abnormal ECG.
Methods : Retrospective review of Pediatric ED charts in all patients aged < 18 years who had ECG
performed during ED stay. Pediatric ED physician interpretation of the ECG, clinical data
on vital signs and past medical history was collected from the medical record for analysis.

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 ABSTRACT
Results : Of 880 ECGs performed in the ED, 17.4% were abnormal. When controlled for medical
history and demographic differences, abnormal ECGs were associated with age-adjusted
abnormal ED vital signs including increased heart rate (odds ratio [OR] 1.85, 95%
confidence interval [CI] 1.1–3.09) and increased respiratory rate (OR 1.74, CI 1.42–2.62).
In a logistic regression analysis, certain chief complaints and history components were
less likely to have abnormal ECGs including complaints of chest pain (OR 0.38, CI
0.18–0.80) and known history of gastrointestinal or respiratory condition (i.e., asthma)
(OR 0.48, CI 0.29–0.79).
Conclusions : In this cohort of patients, those with a chief complaint of chest pain or known respiratory
conditions and normal age-adjusted vital signs in the ED have low likelihood of an
abnormal ECG.
Keywords : Chest pain, children, electrocardiogram, syncope, resource utilization 3
 INTRODUCTION
Electrocardiograms (ECGs) in the pediatric emergency department (PED)
Can be an important
tool to diagnose
cardiac conditions
Previous study: In previously healthy children who
present to the PED with chest pain → cardiac
problem is found in 0.3%–1% of children

Can be costly, time-consuming, and distressing to

family members  false positives, which are
common in pediatric patients. 4
INTRODUCTION
One of the most common reasons PED physicians
obtain an ECG is syncope in children.

• Sanatani et al. distinguishes the most common type,

vasovagal syncope, from cardiac or neurologic
causes of loss of consciousness.
• Only 5 of 480 pediatric patients with syncope were
found to have a cardiac cause.
• A detailed history and physical examination without
an ECG are enough to determine if syncope can be
diagnosed as vasovagal or requires follow-up with a
cardiologist or neurologist.

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 “ Objective of this Study
▰To determine a specific set of clinical variables that are predictive of
abnormal ECGs to risk stratify children presenting to the PED.
▰All chief complaints were included, details regarding medical and
family history were obtained, and both PED and cardiology
interpretations were used.

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 METHODS
▰ STUDY DESIGN RETROSPECTIVE COHORT

▰ TIME JANUARY 1,2010 TO DECEMBER 31, 2010

▰ PLACE PEDIATRIC EMERGENCY DEPARTMENT

(PED)

PATIENTS ≤ 18 YO AND HAD THE ED

▰ PARTICIPANTS PHYSICIAN’S ECG INTERPRETATION
DOCUMENTED IN THE MEDICAL RECORD.
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 METHODS
Variables for Analysis Data Analysis
Demographic variables : Clinical variables →
univariate association
▰ age, gender, race, and insurance type. with an abnormal ECG.

Clinical variables: Logistic regression →

significant lorrelation with
▰ temperature, heart rate (HR), blood a specific outcome
pressure, respiratory rate (RR), room air
oxygen saturation, chief complaint,
medical history, final ED diagnosis, and
ED ECG interpretation, final pediatric
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cardiologist ECG interpretation.
 METHODS
ECGs Abnormal ECGs Normal
Supraventricular Tachycardia (SVT), Bradycardia, Interpretations that
prolonged QTc interval, ST elevation (pericarditis),
were recorded in the chart as “assumed
abnormal T-wave inversions, abnormal axis
(structural heart disease), or left ventricular normal” were
hypertrophy (LVH). classified as normal.

The “ED ECG” interpretation was recorded as the binary outcome for analysis.
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RESULTS

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 RESULTS
▰ 12% of children in the cohort had a significant congenital cardiac medical history, and
6.9% had a history significant for an acquired cardiac problem. Vitals sign
abnormalities for age were present in a small portion of the cohort; abnormal HR was
present in 12.4%, abnormal RR was present in 22%, and abnormal oxygen saturation
was present in 2%.
▰ 17.4% of patients in the study had an abnormal ECG read documented by the PED
physician. The most common abnormalities documented were SVT (48/880),
bradycardia (39/880), prolonged QT interval (29/880), and left ventricular
hypertrophy (18/880).

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RESULTS

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RESULTS

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RESULTS

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Figure 1: Recursive partitioning model stratifying the risk of abnormal electrocardiogram.
Patients with any cardiac medical history were at high risk. Those with age-adjusted 15
tachycardia and/or tachypnea were are intermediate risk
DISCUSSION
▰Decision support tool
may help guide ED 01
clinicians to order ECGs
only in those cases where
the results will change
management.
Previous studies → the
majority of ECGs
performed in the PED are
02 unnecessary and can
often be avoided with a
thorough history and
physical examination
Our study → majority of ECGs done
in the PED do not change clinical
management; however, in patients
03 with a significant cardiac medical
history or objective abnormal age-
adjusted vital signs, ECGs are
more likely to be abnormal.
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 DISCUSSION
In this study, the majority of
chief complaints resulting in
an ECG were for syncope
or chest pain.

Children without significant

cardiac history and with normal
age-adjusted vital signs in this
cohort are less likely to have
abnormal ECGs.

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DISCUSSION
This study highlights some specific elements to be
gathered in the clinical and medical history.
• ECGs in patients with known cardiac history
• those who present with palpitations or syncope who have abnormal age-
adjusted vital signs

Some of the abnormal findings identified in our cohort

• Prolonged QTc, may precipitate potentially fatal cardiac conditions and

require close follow-up.
• ECG findings  change management in a small percentage of patients, in
cardiology consultation in the emergency room (ER) or as an outpatient
and further testing in the ER
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DISCUSSION
Limitation
• Patients who had an ECG done in the ED, which may bias the sample
in favor of patients with higher likelihood of abnormal testing.
• A small percentage of patient data was not interpretable as data
elements were missing from the medical record although this
represented only 4% of all data.
• Finally, this is a single institution, and although this is a large, diverse
cohort of patients, it may not be representative of other institutions

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CONCLUSION
In this study population, the greatest llikelihood of an abnormal ECG is in
children with known cardiac medical history and those with abnormal
age-adjusted HR or RR.

PED patients with a variety of chief complaints without significant cardiac

history and normal age-adjusted HR and RR rarely have abnormal ECGs. In
the cohort of patients with a chief complaint of chest pain, normal age-adjusted
vital signs in the ED reduce the likelihood of an abnormal ECG. Prospectively
developed decision rules in a larger cohort may help further refine these
associations.

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 TELAAH KRITIS JURNAL
TELAAH KRITIS UMUM

No HAL YANG DINILAI CHECK LIST PENILAIAN YA TIDAK

1 Judul Makalah a. Apakah judul tidak terlalu panjang atau pendek? V
b. Apakah judul menggambarkan isi utama penilaian? V
c. Apakah judul cukup menarik? V
d. Apakah judul menggunakan singkatan selain yang baku? V
2 Abstrak a. Apakah merupakan abstrak satu paragraf, atau abstrak V
terstruktur? V
b. Apakah sudah tercakup komponen IMRAC (Introduction,
methods, Results, Conclussion?) V
c. Apakah secara keseluruhan abstrak informatif? (254 kata)
d. Apakah abstrak lebih dari 200 atau 250 kata?
3 Pendahuluan a. Apakah mengemukakan alasan dilakukannya penelitian? V
b. Apakah menyatakan hipotesis atau tujuan penelitian? V
c. Apakah pendahuluan didukung oleh pustaka yang kuat & V
relevan? 21
TELAAH KRITIS UMUM

4 Metode a. Apakah disebutkan design, tempat dan waktu penelitian? V

b. Apakah disebutkan populasi Sumber (populasi terjangkau)? V
c. Apakah kriteria pemilihan (inklusi & eksklusi) dijelaskan ? V
d. Apakah cara pemilihan subjek (teknik sampling) disebutkan? V
e. Apakah perkiraan besar sample disebutkan & disebutkan pula alasannya? V
f. Apakah perkiraan besar sampel dihitung dengan rumus yang sesuai? V
g. Apakah observasi, pengukuran serta intervensi dirinci sehingga orang lain dapat V
mengulanginya? V
h. Bila teknik pengukuran tidak dirinci, apakah disebutkan rujukannya? V
i. Apakah definisi istilah & variable penting dikemukakan?
j. Apakah ethical clearance diperoleh? V
k. Apakah disebutkan rencana analisis, batas kemaknaan & power penelitian? V

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TELAAH KRITIS UMUM

5 Hasil a. Apakah disertakan tabel deskripsi subjek penelitian? V

b. Apakah karakteristik subjek yang penting (data awal) dibandingkan V
kesetaraannya?
c. Apakah dilakukan uji hipotesis untuk kesetaraan ini? V
d. Apakah disebutkan jumlah subjek yang diteliti? V
e. Apakah dijelaskan subyek yang drop out dengan alasannya? V
f. Apakah semua hasil di dalam tabel disebutkan dalam naskah? V
g. Apakah semua outcome yang penting disebutkan dalam hasil? V
h. Apakah subyek yang drop out diikutkan dalam analisis? V
i. Apakah disertakan hasil uji statistik (x2,t) derajat kebebasan (degree of freedom), V
dan nilai p?
j. Apakah dalam hasil disertakan komentar & pendapat? V

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TELAAH KRITIS UMUM

6 Diskusi a. Apakah semua hal yang relevan dibahas? V

b. Apakah dibahas keterbatasan penelitian, dan kemungkinan V
dampaknya terhadap hasil?
c. Apakah disebutkan kesulitan penelitian, penyimpangan dari V
protokol, dan kemungkinan dampaknya terhadap hasil?
d. Apakah pembahasan dilakukan dengan menghubungkannya V
dengan teori dan hasil penelitian terdahulu?
e. Apakah dibahas hubungan hasil dengan praktek klinis? V
f. Apakah kesimpulan didasarkan pada data penelitian? V
g. Apakah efek samping dikemukakan dan dibahas? V
h. Apakah disebutkan hasil tambahan selama diobservasi? V
i. Apakah disebutkan generalisasi hasil penelitian? V
j. Apakah disertakan saran penelitian selanjutnya, dengan V
anjuran metodologis yang tepat?

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TELAAH KRITIS KHUSUS
Validity
1. Apakah awal penelitian didefinisikan dengan jelas?
(pertanyaan penelitian / tujuan penelitian )
Tujuan dari penelitian ini adalah untuk menentukan serangkaian variabel
klinis spesifik yang memprediksi EKG abnormal untuk mengambil risiko
stratifikasi anak yang datang ke PED. Semua keluhan utama dimasukkan,
rincian mengenai riwayat medis dan keluarga diperoleh, dan kedua
interpretasi oleh dokter UGD dan kardiologi digunakan.

2. Apakah menyatakan disain penelitian dengan jelas ?

Desain penelitian adalah kohort retrospektif . Data dikumpulkan secara
retrospektif dari rekam medis elektronik untuk semua pasien yang
menerima EKG di UGD anak dari 1 Januari 2010, hingga 31 Desember
2010. Pasien dimasukkan jika mereka memiliki EKG yang dilakukan di
PED, berusia ≤18 tahun, dan memiliki interpretasi EKG dokter UGD
anak didokumentasikan dalam catatan medis.

3. Apakah pembanding dinyatakan dengan jelas?

Pada penelitian ini tidak dilakukan pembanding. Hanya saja pada tabel
1, demografii pasien dilakukan pembanding antara karakter subjek anak
yang memiliki EKG normal dan anak yang memiliki EKG abnormal
sebagai data awal.
TELAAH KRITIS KHUSUS

4. Apakah faktor kausal dikemukakan ?

Ya, dijelaskan tentang Kriteria untuk kapan dokter harus melakukan pemeriksaan EKG masih kurang.

5. Apakah kelompok-kelompok yang dibandingkan sebanding pada tahap awal ?

Ya sebanding, dapat dilihat di tabel 1, demografi pasien sebagai data awal.

6. Apakah follow up dilakukan secara memadai?

Desain penelitian ini adalah tinjauan retrospektif dimana riwayat medis masa lalu dikumpulkan dari
catatan medis untuk analisis sehingga tidak dilakukan follow up kedepan.
TELAAH KRITIS KHUSUS

Important

1. Apakah outcome / hasil dipaparkan secara jelas (hasil

uji statistik dengan hasil nilai P)?
Hasil dipaparkan dengan jelas dengan menggunakan nilai P.
Nilai p yang signifikan kurang dari 0,05. Dapat dilihat pada tabel
3.

2. Seberapa besarkah ketepatan estimasi outcome yang

didapat dengan nilai OR, RR, PR dengan nilai 95% Cl ?
Dapat di lihat di tabel 4.
TELAAH KRITIS KHUSUS

Aplicability
Jika data valid dan penting, maka data dapat diaplikasikan

1. Apakah karakteristik pasien kita mirip dengan subjek yang diteliti?

Ya. Mirip. karakteristik pasien di RS wahidin sudirohusodo makassar mirip dengan subjek penelitian yaitu
pasien UGD anak dengan berbagai keluhan utama dengan atau tanpa riwayat jantung

2. Apakah bukti ini akan mempunyai pengaruh yang penting secara klinis terhadap
kesembuhan pasien kita tentang apa yang telah ditawarkan / diberikan kepada pasien kita?
Dalam populasi penelitian ini, kemungkinan terbesar dari EKG abnormal adalah pada anak-anak dengan
riwayat medis jantung yang diketahui dan mereka dengan HR atau RR yang disesuaikan dengan usia yang
abnormal. Pasien UGD anak dengan berbagai keluhan utama tanpa riwayat jantung yang signifikan dan HR
dan RR yang sesuai dengan usia jarang memiliki EKG abnormal. Dalam kelompok pasien dengan keluhan
utama nyeri dada, tanda-tanda vital yang disesuaikan dengan usia normal di UGD mengurangi kemungkinan
EKG abnormal. Aturan keputusan yang dikembangkan secara prospektif dalam kelompok yang lebih besar
dapat membantu menyempurnakan asosiasi ini.
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TERIMA KASIH

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 Long QT syndrome

Diagnosis berdasarkan pada temuan selang GT terkoreksi pada EKG yang

lebih besar dari 440 hingga 500 milisekon bersamaan temuan klinis
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Vasovagal syncope

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