ECG Rounds May 201

8/10/2019 ECG Rounds May 201

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Pediatric ECGs

Christine Kennedy

EM RoundsMay 20, 2010


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Objectives

Highlight normal findings on a Pediatric

ECG

T waves

Q waves

ST segments

Identify some key abnormal findings on a

Pediatric ECG (case examples)


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Normal Findings

T waves


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2 week male with ?Apparent Life Threatening Event


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Inverted T waves in V1


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Take home point #1

T waves

Newborn (week 1):

may be either inverted or upright in V1

Between 8 days & 8 years

Shouldbe inverted in V1(if not = RVH)


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Normal Findings

Q waves


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1-year-old male, asymptomatic,

Mom told that child has a murmur


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Q waves in inferior/lat leads


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Take home point #2

Q waves

Q waves are normal in II, III, aVF, V5 & V6

Absence of Q wave: suspect a VSD

Amplitude of accepted Q wave varies with

age

Use lead III as reference

6 months: up to 7 mm

12 months: up to 5 mm

8 years: up to 3 mm


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8 year old boy referred for an irregular heart rhythm


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Sinus rhythm

Varied heart rate


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Take home point #3

Sinus Arrhythmia

Very common in children ages 2-10

Normal variant

Associated with increased vagal tone

Need to have normal P wave morphology

and normal PR intervals*


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11 year old male with chest pain


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Sinus rhythm, rate 60

ST elevation I, II, V2-6


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Take home point #4

ST elevation

Early Repolarization

Normal Variant, common in adolescents

ST elevation


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Now for some abnormal ECGs


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3-year-old girl referred with systolic murmur


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rsR in V1


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Take home point #5

RSR

If R>R in V1

Suspect RVH

25% chance of having ASD


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8 week male with tachypnea


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Left axis deviation [30-135]

RVH: S in V6 >10 [0-10], Q wave in V1

LVH: R in V6 >21 [5-21], Q wave >4mm in V6


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Left axis deviation

RVH: S in V6 >10 [0-10]

LVH: R in V6 >21 [5-21]

AVSD


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Take home point #6

Left Axis Deviation

LAD in first couple of months: suspect

AVSD


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9 year old male with loud systolic murmur at LUSB


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Axis +130

Pure R in V1

S in V6>4 mm


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Take home point #7

RVH

RV dominance & RAD in first couple

months of life is normal

Large amplitude R waves in V1, small

amplitude R waves in V5 & V6

By 5-7 years

Expect more adult norms for R waves R in V1: 0-14

R in V6: 4-25 (4-21 by 16 years)


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4-month-old infant with wheezing and cardiomegaly


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ST elevation in V1-3, 5, V3R, V4R

Inverted T waves in V5-6


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ALCAPAAnomalous Left Coronary Artery

from the Pulmonary Artery


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Take home point #8

ST elevation

Children do get ischemia

If child is irritable with a history of recurrent

wheeze/cough and ST elevation is present,

consider ALCAPA


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Summary

1. T waves Should be inverted in V1between 8 days & 8

years (if not = RVH)

2. Q waves Normal in II, III, aVF, V5 & V6 Absence of Q wave: suspect a VSD

3. Sinus Arrhythmia

Very common in children Look for normal P wave morphology & PR

interval


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Summary

4. Early Repolarization Normal Variant, common in adolescents

ST elevation R in V1, suspect RVH

25% chance of having ASD

6. Left axis deviation If present in first couple of months: suspect AVSD


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Summary

7. RV dominance & RAD Normal in first couple months of life

8. Children do get ischemia If child is irritable with a history of recurrent

wheeze/cough and ST elevation is present,

consider ALCAPA


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Table of LVH/RVH criteria


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Table of Normals


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References

Pediatric ECG Interpretation-An Illustrative

Guide. B.J. Deal, C.L. Johnsrude, S.H.

Buck.

The Pediatric ECG. G.Q. Sharieff, S.O.

Rao. Emerg Med Clin N Am 24 (2006).

195-208.


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Other Pearls

PR interval short at birth (0.08-0.15), increaseswith increasing muscle mass

QRS shorter Abnormal If >0.08 in children

ECG Rounds May 201

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