Tachypnea of Infancy as the First Sign of Sanfilippo Syndrome abstract
ECG Rounds: Dr. Dave Dyck R3 April 3, 2003. Case 1: 2 week infant with tachypnea (RR=60-70),...
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Transcript of ECG Rounds: Dr. Dave Dyck R3 April 3, 2003. Case 1: 2 week infant with tachypnea (RR=60-70),...
ECG Rounds:Dr. Dave Dyck R3
April 3, 2003
Case 1: 2 week infant with tachypnea (RR=60-70),
tachycardia (170) and “dusky” in appearance.
Cardiologists Interpretation: Sinus rhythm. Heart Rate 160. QRS axis 90. PR 130ms. QRS 50ms. QT/QTc
280/450 Right atrial hypertrophy Right ventricular hypertrophy LV strain/ischaemia
Of Note: The T wave changes are the most significant features of this
ECG.
An upright T wave in V1 in a 2 week old infant is abnormal and may signify RV systolic hypertension.
Inverted T waves in V5-6 are evidence of LV strain which may cause reciprocally upright T waves in the right chest leads.
(TGA/VSD/PA)
Case 2: 13m female with failure to thrive and
worsening tachypnea sent to ER by GP HR=125 RR=42 O2sat=94%
ECG:
Cardiologist’s Interpretation: Sinus rhythm. Rate 124. QRS axis +150.
PR 150ms. QRS 60ms. QT/QTc 240/340Bi-atrial hypertrophy, left >rightRight axis deviationRight ventricular hypertrophy
(upright T waves in V1= abnormal)
ECG:
Of Note: This young child was born with a dysmorphic
mitral valve which has resulted in both mitral stenosis and incompetance.
The right sided hypertrophy is a result of pulmonary hypertension caused by her elevated left heart pressures.
Pediatric ECGs Often 13 lead ECGs done (V3R or V4R) for
the evaluation of RVH in children
V1 inverted Ts: 1st day = RAD, large R waves + upright T
waves in right precordial leads (V3R, V1) by 48 hrs: inverted T waves in V1, V3R
Upright Ts > 1 wk pathologic (RVH or strain)
Should never be upright before age 6 and often into adolescence
Axis: Newborn Axis: usually +110 - +180 V1, V3R have R>S wave usually and often
for months/years (up to 8 yrs) Over the years, the QRS axis gradually shifts
leftward and right ventricular forces slowly regress
If it looks like a normal adult ECG early on think LVH
Pediatric Heart Chamber Hypertrophy: Right Atrial Enlargement (RAE):
P wave > 2 mm tall in infants and small children and > 3 mm tall in older children
P waves best seen in inferior (I,II & aVF) and the right chest leads (V3R, V1 & V2)
RAE:
Left Atrial Enlargement: Wide P waves > 2 mm wide (.08s) in infants
and small children and more than 3 mm wide (.12s) in larger children
Best seen in inferolateral leads
LAE:
P wave morphology in AE:
Right Ventricular Hypertrophy: R in V1 >95% of normal + S in V6 deeper than
95% of normal
Age HRbpm
QRSaxis
degrees
PRintervalseconds
QRSintervalseconds
Rin V1mm
Sin V1mm
Rin V6mm
Sin V6mm
1st week 90-160 60-180 0.08-0.15 0.03-0.08 5-26 0-23 0-12 0-10
1-3wks 100-180 45-160 0.08-0.15 0.03-0.08 3-21 0-16 2-16 0-10
1-2 mo 120-180 30-135 0.08-0.15 0.03-0.08 3-18 0-15 5-21 0-10
3-5 mo 105-185 0-135 0.08-0.15 0.03-0.08 3-20 0-15 6-22 0-10
6-11 mo 110-170 0-135 0.07-0.16 0.03-0.08 2-20 0.5-20 6-23 0-7
1-2 yr 90-165 0-110 0.08-0.16 0.03-0.08 2-18 0.5-21 6-23 0-7
3-4 yr 70-140 0-110 0.09-0.17 0.04-0.08 1-18 0.5-21 4-24 0-5
5-7 yr 65-140 0-110 0.09-0.17 0.04-0.08 0.5-14 0.5-24 4-26 0-4
8-11 yr 60-130 -15-110 0.09-0.17 0.04-0.09 0-14 0.5-25 4-25 0-4
12-15 yr 65-130 -15-110 0.09-0.18 0.04-0.09 0-14 0.5-21 4-25 0-4
> 16 yr 50-120 -15-110 0.12-0.20 0.05-0.10 0-14 0.5-23 4-21 0-4
RVH #2 rsR’ in V1 & V2 without a widened QRS duration
as in RBBB (note= 2nd R is larger)
RVH #3 qR in V1 and V2
RVH #4
Pure R in V1 & V2 +/- strain changes
Left Ventricular Hypertrophy (LVH): S in V1 deeper than 95% of normal and R in V6
taller than 95% of normal
Summary: From 5 days to age 6, upright T waves in V1 are
abnormal. RAD (& V3R, V1 R>S) is prominent early and is
normal RVH in kids
1. R in V1>95% of normal and S in V6 deeper than 95% 2. RsR’ in V1(2) without widened QRS 3. qR in V1(2) 4. pure R in V1(2) +/- strain
Ventricular hypertrophy in children is based on comparison to statistical norms