ECG Workshop:The ABC of Pediatric ECG

M. Hamdan, MD

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Normal Values

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GOLDEN RULE..!

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Forget Internal Medicine

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14-Lead EKG

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Nomenclature

Right leadsaVR, V1, V3R, V4R

Left Leads I, aVL, V6

Inferior Leads II, III, aVF

Transitional LeadsV2-V5 IGNORE

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Practical Approach

B) LIMB LEADS C) CHEST LEADS

1. Rate 1. T waves (V1 & V6)

2. Axis (P& QRS) 2. R & S (V1 & V6)

3. NSR 3. RSR’ (V1)

4. P waves & PR interval (II) 4. ST Segments

5. Q waves (III) 5. QTc

A) Age/ Calibration/ Speed

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A) Age/ Calibration/ Speed

A.1) Speed:25 mm/sec 1 small box = 0.04 sec (or 40 msec) 1 large box = 0.2 sec (or 200 msec)

A.2) Calibration:1 mV = 10 mm 1 small box = 1 mm (0.1 mV)

½ standard: 1 mV = 5 mm 1 small box = 0.2 mV (voltages x 2)

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Full Standard Calibration

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1/2 Standard Calibration

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Electronic Interpretation

GOOD for: rate, axis, intervals, RVH

OK for: LVH

BAD for: ST changes, Q waves, rhythm, QTc

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10 yrs

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B) Limb Leads

1. Rate2. Axis (P&QRS) in I & aVF3. NSR4. P-waves & PR interval (II)5. Q-waves

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Heart Rate

60 000/ RR interval in msec.1 small box = 0.04 sec = 40 mesc.

The ‘Box’ method 300/No. of large boxes1500/No. of small boxes

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B) Limb Leads

1. Rate2. Axis (P&QRS) in I & aVF3. NSR4. P-waves & PR interval (II)5. Q-waves

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B2) P-wave Axis

0+180

-90

P in Lead I

P in Lead aVF+90

NormalHigh RA Rhythm

LowRA Rhythm

LowLA Rhythm

HighLA Rhythm

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9 yrs+ I

+ aVF

Normal(High RA)

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6 yrs

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6 yrs+ I

- aVF Abnormal(Low RA)

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B2) QRS Axis

QRS Axis

NormalRAD

LADLAD

RAD

0

+120

+180

-90

Lead I

Lead aVF+90

NW AxisSuperior Axis

Normal

Left Axis Deviation is

NEVER normal

(When QRS is –ve in aVF)

Causes of LAD in Pediatrics

1. AV canal (partial or complete)2. Tricuspid atresia3. WPW4. Single ventricle5. Left aneteior hemiblock6. + LVH

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20 months Left Axis Deviation

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5 yrs Left axis deviationNW-axis

B) Limb Leads

1. Rate2. Axis (P&QRS) (I & aVF)

3. NSR (Normal Sinus Rhythm)4. P-waves (II)5. Q-waves

Normal Sinus Rhythm

1. Normal P-wave axis +ve in I & aVF

2. One P : One QRS3. Fixed P-wave morphology4. Fixed PR interval

I (+)

aVF (+)

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2 yrs Normal sinus rhythm

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7 yrs

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7 yrs

+ I

- aVFLow RA rhythm

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11 yrs

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11 yrs

- aVF

+ I

Different P-wave axisDifferent P-wave morphology

Wandering Pacemaker

B) Limb Leads

1. Rate2. Axis (P&QRS) (I & aVF)3. NSR 4. P-waves & PR interval (II)5. Q-waves

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B4) P-Waves

Lead II Normal:

2.5 X 2.5 boxes 0.09 s X 2.5 mm

Abnormal: RAE (P-pulmonale) LAE (P-mitrale)

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2 month

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2 yrs

B4) PR Interval

Regardless the age:Normal 0.08-0.16 (2-4 small squares)

Prolonged PR1st- degree AV block: No clinical significance Common in: ASD, repaired TOF

Short PR interval:WPWPompe

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B) Limb Leads

1. Rate2. Axis (P&QRS) (I & aVF)3. NSR 4. P-waves & PR interval (II)5. Q-waves

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B5) Q-Waves

Not infarction Ventricular septum

Look for lead III value for age Normal:

Inferior leads, aVR & V6 Up to 1 box wide X 5 boxes height

(0.04 sec X 5 mm) Abnormal:

Leads I & aVL (ALCAPA) Wide (> small square = 0.04 sec.) (Infarction) Deep ((> 95th percentile for age) (LVH)

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2 years2 yrs

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4 months

LVH

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7 months

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C) Chest Leads

1. T-waves (V1 & V6)2. RSR’3. R & S (V1 & V6)4. ST segments5. QTc

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C) Chest Leads

1. T-waves (V1 & V6)2. RSR’3. R & S (V1 & V6)4. ST segments5. QTc

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C1) T-Waves

AGE V1 V6

< 1 wk + +

1 wk- adolescence - +

> adolescence + +

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1 day old1 day

Normal T-waves

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3 months

Normal T-waves

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6 years

Normal T-waves

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T-Waves

3 wks

15 yrs

Normal T-waves

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3 wks

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3 wks Flat T-waves in V1: RVH

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7 mo.

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7 mo. +ve T-waves in V1: RVH

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C) Chest Leads

1. T-waves (V1 & V6)2. RSR’ (V1)3. R & S (V1 & V6)4. ST segments5. QTc

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C2) RSR’

Common in pediatrics: V1

Can be:NormalRVHRBBB

R

S

R’

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C2) RSR’ in V1

Normal

< 10 mm

RVH

>= 10 mm

Height of R' ?

<= 0.08 sec

Incomplete RBBB

0.08-0.09 sec

RBBB

> 0.09 sec

QRS duration

R

S

R’

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6 yrsQRS= 0.07 sec

Normal

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16 mo. QRS= 0.05 secRVH

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3 yrs RBBB

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8 yrs QRS= 0.12 sec.

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8 yrs QRS= 0.12 sec.

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8 yrs QRS= 0.12 sec.

RBBB

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C) Chest Leads

1. T-waves (V1 & V6)2. RSR’ (V1)

3. R & S (V1 & V6)4. ST segments5. QTc

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R & S Waves8 yrs

S1 &/or R6 >98%: LVH

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C) Chest Leads

1. T-waves (V1 & V6)2. RSR’ (V1)3. R & S (V1 & V6)4. ST segments5. QTc

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2 days ST depression or elevation >1mm

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C) Chest Leads

1. T-waves (V1 & V6)2. RSR’ (V1)3. R & S (V1 & V6)4. ST segments

5. QTc

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1. Find a nice Q & T

2. Find regular HR

3. Measure Q-T (multiply by 0.04) & 4. Measure preceding RR (multiply by 0.04)

5. Bazzet’s formula: QTc= QT / RR

How to calculate QTc Interval?

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Step-Wise Approach

B) Limb Leads1. Rate2. Axis (P&QRS)3. NSR 4. P waves & PR

interval (II)5. Q waves (III)

C) Chest Leads1. T waves2. RSR’ (V1)3. R & S in (V1 & V6)4. ST segments5. QTc

A) Age/ Calibration/ Speed

Workshop

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#1: 16 months

NSRRADBorderline RAERVH

TOF, Sec. ASD, PS, Pulm. HTN

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#2: 2 months

NSRLADRVH

Tri atresia, AV canal

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#3: 4 yrs

NSRLAD (NW axis)RBBBLAD+RBBB= Bi-fasicular block

Always after surgery for: TOF, Truncus, VSD, AV canal

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#4: 7 yrs

Low RA rhythm Normal variation, PAC’s, Sinus venosus ASD

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#5: 8 yrs

NSR with 1st degree AVB+ BAELADRBBB

Always after surgery: TOF, Truncus, AV canal

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#6: 10 yrs

NSR with suns arrhythmia Normal

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#7: 5 months

NSRBVH with strainShort PR

Classical Pompe EKG

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#8: 1 yr

NSRBVH VSD, Cardiomyopathy

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#9: 12 yrs

NSR Long QT syndrome

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#10: 5 yrs

NSRLADShort PRDelta wavesWide QRSAbsent Q in V6

WPW

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#11: 11 yrs

Wandering pacemaker Normal, PAC’s

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#12: 2 yrs

Complete AV blockJunctional escape rhytm Complete AVB

STOP

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What’s this ?#13: 6 years

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What’s this ?

NSRLADShort PRDelta wavesAbsent Q in V6

WPW)

#13: 6 years

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#1: 3 months

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Example 1: Tricuspid Atresia

HR 135 NSR LAD RAE RVH LVH BVH

3 months

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# 2: 6 years

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Example 2: TOF

HR 80 NSR RAD RVH

6 years

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# 3: 6 months

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Example 3: VSD

HR 150 NSR LVH

15 years# 3: 6 months

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# 4: 10 years

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Example 4: HCM

HR 60 NSR RVH LVH BVH ‘Strain’

10 years

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# 5: 3 years

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Example 5: LQTS

HR 94 NSR BVH QTc 0.54

5 years

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#6: 2 years

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Example 6: TOF s/p repair

HR 130 LAD RBBB

10 years2 years

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3 yrs

NSRRAELVH

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8 yrs

NSRLAD (NW axis)RAE