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Pediatric ECG’s

Pediatric ECG’s. Christine Kennedy EM Rounds May 20, 2010. 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). Normal Findings . T waves.

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Pediatric ECG’s

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  1. Pediatric ECG’s Christine Kennedy EM Rounds May 20, 2010

  2. 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)

  3. Normal Findings T waves

  4. 2 week male with ?Apparent Life Threatening Event

  5. Inverted T waves in V1

  6. Take home point #1 T waves • Newborn (week 1): • may be either inverted or upright in V1 • Between 8 days & 8 years • Should be inverted in V1 (if not = RVH)

  7. Normal Findings Q waves

  8. 1-year-old male, asymptomatic, Mom told that child has a murmur

  9. Q waves in inferior/lat leads

  10. Take home point #2Q 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

  11. 8 year old boy referred for an irregular heart rhythm

  12. Sinus rhythm • Varied heart rate

  13. Take home point #3Sinus 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*

  14. 11 year old male with chest pain

  15. Sinus rhythm, rate 60 ST elevation I, II, V2-6

  16. Take home point #4ST elevation • Early Repolarization • Normal Variant, common in adolescents • ST elevation <25% of T wave height • Symmetric T waves

  17. Now for some abnormal ECG’s

  18. 3-year-old girl referred with systolic murmur

  19. rsR’ in V1

  20. Take home point #5RSR’ • If R’>R in V1 • Suspect RVH • 25% chance of having ASD

  21. 8 week male with tachypnea

  22. 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

  23. Left axis deviation RVH: S in V6 >10 [0-10] LVH: R in V6 >21 [5-21] AVSD

  24. Take home point #6 Left Axis Deviation • LAD in first couple of months: suspect AVSD

  25. 9 year old male with loud systolic murmur at LUSB

  26. Axis +130 Pure R in V1 S in V6>4 mm

  27. Axis +130 Pure R in V1 S in V6>4 mm Pulmonary Stenosis

  28. Take home point #7RVH • 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)

  29. 4-month-old infant with wheezing and cardiomegaly

  30. ST elevation in V1-3, 5, V3R, V4R Inverted T waves in V5-6

  31. ALCAPAAnomalous Left Coronary Artery from the Pulmonary Artery

  32. Take home point #8ST elevation • Children do get ischemia • If child is irritable with a history of recurrent wheeze/cough and ST elevation is present, consider ALCAPA

  33. Summary • T waves • Should be inverted in V1 between 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

  34. Summary 4. Early Repolarization • Normal Variant, common in adolescents • ST elevation <25% of T wave height 5. RSR’ • If R’>R in V1, suspect RVH • 25% chance of having ASD 6. Left axis deviation • If present in first couple of months: suspect AVSD

  35. Summary • 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

  36. Table of LVH/RVH criteria

  37. Table of Normals

  38. 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.

  39. Other Pearls • PR interval short at birth (0.08-0.15), increases with increasing muscle mass • QRS shorter • Abnormal If >0.08 in children <8 years • LVH • LV strain in V5&V6 (flipped T’s), mature precordial R wave progression in newborn • Sinus tachycardia • When febrile, expect HR to increase by 10 for every degree elevation in temperature

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