Pediatric ecg
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The Pediatric ECG
DR MANDAR HAVALDR MANDAR HAVAL
DCH.DNBDCH.DNB
Objectives
Review the cardiac physiology with respect to age, and age related normals
Discuss wave morphology and axis as it relates to age and ventricular dominance
Review intervals and other “differences” in the pediatric ECG
Discuss an approach to interpretation of chamber enlargement
Review some basic tachyarrythmias common in children
Normal variants and osce on ECG
Background
ECG changes during the first year of life reflect the switch from fetal to infant circulation, changes in SVR, and the increasing muscle mass of the LVThe size of the ventricles changes as the infant grows into childhood and adulthoodThe RV is larger and thicker at birth because of the physiologic stresses on it during fetal developmentBy approximately 1 month of age, the LV will be slightly largerBy 6 months of age, the LV is twice the size of the RV, and by adolescence it is 2.5 times the size
Heart rate Average heart rate peaks at second month of life, then
gradually decreases
Resting HRs start at 140 bpm at birth, fall to 120 bpm at 1 year, 100 bpm at 5 years, and adult ranges by 10 years
• • INTRINSIC HEART RATESINTRINSIC HEART RATES
Newborn to 3 years:Newborn to 3 years:
• SA node 95 – 120
• AV node (junctional) 45 – 85
• Purkinje (ventricular) 35 – 55
3 years to teenager
• SA node 55 – 120
• AV node (junctional) 35 – 65
• Purkinje (ventricular) 25 ‐ 45
Age Related Normal Findings
Tables exists that include age based normal ranges for heart rate, QRS axis, PR and QRS intervals, and R and S wave amplitudes
After infancy, changes become more subtle and gradual as the ECG becomes more like that of an adult
The P Wave
Best seen in leads II and V1
P wave amplitude does not change significantly during childhood
Amplitudes of 0.025 mV should be regarded as approaching the upper limit of normal
The QRS Complex
QRS complex duration is shorter, presumable because of decreased muscle mass
QRS complexes > 0.08 sec in patients < 8 years is pathologic
In older children and adolescence a QRS duration > 0.09 sec is also pathologic
The T Wave
The T waves are frequently upright throughout the precordium in the first week of lifeThereafter, T waves in V1-V3 invert and remain inverted from the newborn period until 8 years of ageThis is called the “juvenile T wave pattern”, and can sometimes persist into adolescenceUpright T waves in the right precordial leads in children can indicate right ventricular hypertrophy
3 day old & 7 y/o
QRS Axis and Ventricular Dominance
At birth, the axis is markedly rightward (+60 - +160), the R/S ratio is high in V1 and V2 (large precordial R waves), and low in V5 and V6As the LV muscle mass grows and becomes dominant the axis gradually shifts (+10 - +100) by 1 year of age, and the R wave amplitude decreases in V1 and V2 and increases in V5 and V6
What is the axis?
What is the axis?
LAD
NormalRAD
Lead I
AVF
Negative
+
+_
Lead I AVF
Normal Positive Positive
RAD Negative Positive
LAD Negative Negative
What is the axis?
RIGHTAXISDEVEATION
What is the axis?
LAD
What is the axis?
NORMAL
CHAMBER HYPERTROPHY
Interpretation?
Right atrial enlargement Right atrial enlargement
DIGNOSIS?
Left atrial Left atrial enlargementenlargement
Atrial Enlargement
RAE is diagnosed in the presence of a peaked tall P wave in II
In the first 6 months, the P wave must be >3 mm to be pathologic; then >2 mm is abN
LAE can be diagnosed with a biphasic P wave in V1 with a terminal inferior component
The finding of a notched P wave in II can be a normal variant in 25% of pediatric ECGs
Interpretation?
Right ventricular hypertrophy (RVH)
RVH
Large R wave in V1 and large S wave in V6
Upright T wave in V1-V3
RAD
Persistent pattern of RV dominance
Right Ventricular Hypertrophy
Diagnosis depends on age adjusted values for R wave and S wave amplitudesA qR complex or rSR’ pattern in V1 can also be seenUpright T waves in the right precordial leads, RAD, and complete reversal of adult precordial pattern of R and S waves all suggest RVH Lead V1with the R height
> 15 mm IN < 1YR & >10mm IN > 1 YR
RVHRVH
Interpretation?
Left ventricular hypertrophy (LVH)
LVH
R wave > 98th percentile in V6 and S wave > 98th percentile in V1
LV “strain” pattern in V5 and V6 or deep Q waves in left precordial leads
“Adult” precordial R wave progression in the neonate
CONDUCTION CONDUCTION ABNORMALITIESABNORMALITIES
Bundle branch blocks are diagnosed as they would be in adults; RBBB occurs most commonly after repair of congenital heard defects and LBBB is very rare
First degree AV block and Mobitz type 1 (Wenckebach) can be a normal variant in 10% of kids
Complete AV block is usually congenital or secondary to surgery
Sinus Bradycardia
Deviation from NSR
- Rate < 60 bpm Etiology: SA node is depolarizing slower than
normal, impulse is conducted normally (i.e. normal PR and QRS interval).
Sinus Tachycardia
Deviation from NSR
- Rate > 100 bpmEtiology: SA node is depolarizing faster than normal, impulse is conducted normally.
Remember: sinus tachycardia is a response to physical or psychological stress, not a primary arrhythmia.
Interpretation?
Sinus Tachycardia
1st Degree AV Block
Etiology: Prolonged conduction delay in the AV node or Bundle of His.
Diagnosis?
p
1st Degree AV Block
FIRST DEGREE HEART FIRST DEGREE HEART BLOCKBLOCK
PR interval > 5 small divisions, 0.2 secs
Causes: myocarditis, acute rheumatic fever, drugs,
50 bpm• Rate?• Regularity? regularly irregular
nl, but 4th no QRS
0.08 s
• P waves?
• PR interval? lengthens• QRS duration?
Interpretation? 2nd Degree AV Block, Type I
2nd Degree AV Block, Type I
Deviation from NSR PR interval progressively lengthens, then
the impulse is completely blocked (P wave not followed by QRS).
40 bpm• Rate?• Regularity? regular
nl, 2 of 3 no QRS
0.08 s
• P waves?
• PR interval? 0.14 s• QRS duration?
Interpretation? 2nd Degree AV Block, Type II
2nd Degree AV Block, Type II
Deviation from NSR Occasional P waves are completely
blocked (P wave not followed by QRS). Etiology: Conduction is all or nothing (no
prolongation of PR interval); typically block occurs in the Bundle of His.
MOBITZ TYPE 2
Rhythm #13
40 bpm• Rate?• Regularity? regular
no relation to QRS
wide (> 0.12 s)
• P waves?
• PR interval? none• QRS duration?
Interpretation? 3rd Degree AV Block
Diagnosis?
3rd Degree AV Block
Diagnosis?
RBBB
RIGHT BUNDLE BRANCH RIGHT BUNDLE BRANCH BLOCKBLOCK
Wide QRS > 0.12 s ( 3 small divisions)
M morphology in V1V1
“Rabbit Ears”
Diagnosis?
LBBB
LEFT BUNDLE BRANCH LEFT BUNDLE BRANCH BLOCKBLOCK
Wide QRS > 0.12 s ( > 3 small divisions)
M morphology in V 6 and W in V1
ARRHYTHMIAS
13 y/o with palpitations
Paroxysmal supraventricular tachycardia (PSVT)
22 day old with poor feeding
Paroxysmal supraventricular tachycardia (PSVT)
Diagnosis?
Paroxysmal supraventricular tachycardia (PSVT)
Paroxysmal supraventricular tachycardia (PSVT)
Regularity: Regular
Rate : >180/min
P wave morphology: Different from sinus P wave or lost in preceeding T wave
PR interval: 0.12 – 0.20 secs ( normal)
QRS interval: normal (<0.08 s)
Pattern: Sudden onset and offset
Diagnosis
What is the rate?
Is the QRS wide or narrow?
Causes
Ventricular tachycardia
Ventricular tachycardia
Rate > 120 / min
QRS > 0.08 secs
Causes: myocarditis, LCAPA, tumour, Long QT, drugs, surgery
Diagnosis?
Torsades de pointis
Torsades de pointis
Torsades de pointis
Gradual change in amplitude of QRS
Rate 150-250/min
Prolonged QT interval, Hypokalemia, hypomagnesemia, drugs
Diagnosis?
Ventricular fibrillation
Chaotic rhythm with wide QRS
Causes: terminal rhythm in cardiac arrest
70 bpm• Rate?• Regularity? regular
flutter waves
0.06 s
• P waves?
• PR interval? none• QRS duration?
Interpretation? Atrial Flutter
Atrial Flutter
Deviation from NSR No P waves. Instead flutter waves (note
“sawtooth” pattern) are formed at a rate of 250 - 350 bpm.
Only some impulses conduct through the AV node (usually every other impulse).
QUESTIONS
1. 2 year old with syncope and VT
LONG QT SYNDROMELONG QT SYNDROME
Intervals
PR and QRS durations are relatively short from birth to age 1 and gradually lengthen during childhood; corrected QT (QTc) should be calculated on all pediatric ECGs
During the first 6 mo of life, the QTc is slightly longer and is considered normal below 0.49 sec
After that, any QTc above 0.44 sec is abnormal
Other features of long QT syndrome include notched T waves, abnormal U waves, relative bradycardia and T wave alternans
LONG QT SYNDROMELONG QT SYNDROME
LONG QT – SYNDROME.
N-QTc- Infants 0.44 & NB-0.49sec
1.Beta-Blockers .Avoid drugs known to prolong QT-interval , electrolyte imbalance.2.SOS pacemaker . W/F Syndromes associated with Long QT-interval.3. Avoid competitive sports and swimming, teach CPR to the caretakers. Inform about SIDS.
14-year old girl
•Asymptomatic now
•Intermittent palpitations, no syncope
•SO2: 94%
•Split S2, multiple heart sounds, no murmurs
CASE 2CASE 2
EBSTEIN ANOMALY
Sinus, Tall P, splintered QRS
CASE 3 DILATED CARDIOMYOPATHYDILATED CARDIOMYOPATHY
There is marked LVH (S wave in V2 > 35 mm) with dominant S waves in V1-4.
Right axis deviation suggests associated right ventricular hypertrophy (i.e. biventricular enlargement).
There is evidence of left atrial enlargement (deep, wide terminal portion of the P wave in V1).
There are peaked P waves in lead II suggestive of right atrial hypertrophy (not quite 2.5mm in height).
4. INTRPREAT ECGHYPERKALEMIA
• Changes appear when K+ falls below about 2.7 mmol/l• Increased amplitude and width of the P wave• Prolongation of the PR interval• T wave flattening and inversion• ST depression• Prominent U waves (best seen in the precordial leads)• Apparent long QT interval dueto fusion of the T and U waves
HYPOKALEMIA- HYPOKALEMIA- ECGECG
5.
WPW SYNDROMEWPW SYNDROME6.6.
69
Delta wave
•WPW- 3 features
•Short PR interval ,
•Delta wave on upstroke of QRS
•Slightly wide QRS
Station 1.a 1 day old neonate with respiratory distress ECG done
What are ECG features?
What is diagnosis?
What disorders are associated?
What precaution to be taken in emergency with such patients
7)
Inverted p/t wave, -ve qrs in lead 1.lead 2 n 3 reversed.lead 2 resemble 3 and 3 resemble 2
DEXTROCARDIA
number of bowel, esophageal, bronchial and cardiovascular disorders (such as double outlet right ventricle, endocardial cushion defect and pulmonary stenosis) Kartagener syndrome
Place rt Up N lt Lo lead on Up lft N Lo rt
ATRIAL FIBRILLATIONATRIAL FIBRILLATION8.
Atrial activity is chaotic
Station No;9A 10 day old newborn was rushed to NICU by a local doctor as he found
different pattern of his cardiac activity. O/E child had fine rashes over the face specially the periorbital area . ECG done in ER showed (1x5=5)
a) What is the ECG diagnosis? b )What is probable diagnosis?
c) What is the pathogenesis of this disease?
d) What is the Rx of this acute stage?
e) What is the earliest age at which this cardiac defect can detected antenatally?
A)COMPLETE HEART BLOCK
b) Neonatal Lupus
c) Transfer of anti Ro antibodies between 12-16 wks of gestation
d) Cardiac pacing
e) 16 wks of GA
10
2 months old baby admitted with recurrent cough cold, irritability, dyspnea and sweating. EKG done What is the diagnosis? (1/2)Name 4 EKG findings that helped u in diagnosis (1)What is the diagnostic test?(1/2)Name treatment options of it.(1)
Answer
ALCAPAALCAPA
Inverted T wave, V5-V6 deep Q wave,ST elevation , inverted T wave
Cardiac catherization
Medical t/ t for CCF, ishamia and Surgical excision and ligation
ALCAPA_ECG # Description : ECG. Left axis deviation with left ventricular hypertrophy. Signs of anterolateral myocardial infarction: deep Q waves with T waves inversions in leads I, avL and deep Q waves with ST elevation in the left precordial leads.
A 12 yr old male child with c/o jt pain and fever admitted in ER.ECG done showed.What does this EKG strip shows (1)Name 3 EKG findings that helped you in diagnosis (1)What are the 2 clinical findings which will indicates severity?(1)Name treatment options of it.(1)What are other differential diagnosis?(1)
11
Answer
RHEUMATIC PERICARDITIS
Low voltage QRS, elevation of ST, Twave inversion
Friction Rub and Pulsus Paradoxus
steroid
Viral Pericarditis, Benign Pericarditits, JRA
PERICARDITIS
Diffuse upsloping ST segment elevations seen best here in leads II, III, aVF, and V2 to V6
1212
MYOCARDITISMYOCARDITIS
Sinus tachycardia with non-specific ST segment changes
1313
14
Name the wave marked by the asterisk
In which condition will you find it?
Which serious arrhythmia can it lead to?
How will you treat it?
J WAVE,OSBORNE WAVE
Hypothermia
Ventricular arrhythmia
Rewarm the patient
ECG showing R wave in lead V1 with RS in V2 (sudden transition), Right axis deviation , no q waves in lateral leads suggesting decreased pulmonary blood flow
TETROLOGY OF FALLOT (TOF)15
PERICARDIAL EFFUSION
Sinus tachycardia with low QRS voltage and QRS alternans
16
ASDASD
There is right axis deviation with tall R waves V1-3 and corresponding deep S waves in V4-6. T waves are flat in V1 and inappropriately upright in V2-3. There is the RsR' pattern in V1 of partial rightbundle branch block.
17
VSDVSD
The Katz-Wachtel sign Katz-Wachtel sign is tall diphasic RS complexes at least 50 mm in height in lead V2, V3 or V4 – mid precordial leads
1818
PREMATURE BEATS
Premature Ventricular Contraction
Premature Atrial Contraction
Normal Variants
Sinus arrythmia Can be quite marked Slows on expiration and
speeds up on inspiration
Extrasystoles Can be atrial or venticular
and are usually benign in the context of a structurally normal heart; typically monomorphic and associated with slower heart rates
Abolish with excercise
The Pediatric ECG…
In Summary
Consider the age of the child, and the cardiac forces that may be dominantUse a structured approach and assess morphology, axis, and intervals in the context of age related normalsEvaluate for the presence of structural diseaseRemember the “normal variants”
THANKTHANK YOUYOU
ALL THE BESTALL THE BEST