Approach to Pediatric ECG September 22, 2005 Sultana Qureshi.

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Presentation transcript:

Approach to Pediatric ECG September 22, 2005 Sultana Qureshi

Indications Definitely: Definitely: Syncope Syncope Exertional symptoms Exertional symptoms Tachycardia/Bradycardia Tachycardia/Bradycardia Palpitations Palpitations ECG not as useful in isolated chest pain in kids ECG not as useful in isolated chest pain in kids Other indications: Other indications: Seizure Drug ingestion Heart failure Cyanotic Episodes Hypothermia Electrolyte disturbance Kawasaki Disease Rheumatic Fever Myocarditis/Pericarditis Congenital Heart Disease Myocardial Contusion Post cardiac surgery

Pediatric ECG findings that may be normal Heart Rate >100 bpm Heart Rate >100 bpm Sinus Arrythmia Sinus Arrythmia QRS Axis >+90° QRS Axis >+90° Shorter intervals (PR, QT, duration of QRS, etc) Shorter intervals (PR, QT, duration of QRS, etc) T-wave inversion of right precordial leads T-wave inversion of right precordial leads Dominant Right precordial R-waves Dominant Right precordial R-waves Q-waves (inferior and lateral leads) Q-waves (inferior and lateral leads) ST elevation due to early repolarization ST elevation due to early repolarization

Development of the Heart (Relative to ECG findings) At Birth At Birth Thickness of RV > LV Thickness of RV > LV ECG = RAD (60°-160°) & ECG = RAD (60°-160°) & = RV dominance in precordial leads = RV dominance in precordial leads = T-wave upright in V 1 -V 3 = T-wave upright in V 1 -V 3 6 months 6 months Adult proportions of ventricles Adult proportions of ventricles ECG = LV dominance ECG = LV dominance = T-wave inverted in V 1 -V 3 1 year 1 year QRS Axis 10° ° QRS Axis 10° ° Pulmonary vascular resistance Systemic Vascular Resistance

Step 1: Identify AGE! Approach to Pediatric ECG

Step 2: Heart Rate Approach to Pediatric ECG TABLE Age-Specific Rates Age Beats per minute Range (degrees)Mean First week100– week to 3 months85– –12 months110– –3 years98– –5 years65– –8 years70– –16 years55–10779 Rosen (2005)

Step 2: Heart Rate Approach to Pediatric ECG

Step 2: Heart Rate Approach to Pediatric ECG Sinus Arrythmia more common and profound in children clinical correlation

Step 3: Rhythm Approach to Pediatric ECG Same analysis as adults Age specific Intervals For the pediatric cardiologists! Also measure P-axis in rhythm analysis for source of ectopic foci

Step 3: Rhythm Approach to Pediatric ECG AgeHR bpm QRS axis degrees PR interval seconds QRS interval seconds R in V1 mm S in V1 mm R in V6 mm S In V6 mm 1st week wks mo mo mo yr yr yr yr yr > 16 yr

Step 4: QRS Axis Approach to Pediatric ECG 3 days old 12 years old

Step 4: QRS Axis Approach to Pediatric ECG TABLE Age-Specific QRS Axis (Frontal Plane) Age Range (degrees) Mean (degree) 1–7 days80– –4 weeks30– –3 months10– –6 months20–8065 6–12 months 0– –3 years20– –8 years20–12060

Step 5: Specific Waveforms Large right precordial R-waves (RV dominance) Large right precordial R-waves (RV dominance) T-wave inversion of V 1 - V 3, V 4 R T-wave inversion of V 1 - V 3, V 4 R Juvenile T wave variant (normal from 7d- 7y) Juvenile T wave variant (normal from 7d- 7y) Abnormal if T-waves upright between 7d -7y, and indicator of RVH (even if do not meet voltage criteria for RVH) Abnormal if T-waves upright between 7d -7y, and indicator of RVH (even if do not meet voltage criteria for RVH) Q-waves (inferior and lateral leads) Q-waves (inferior and lateral leads) ST elevation from Early Repolarization, and J-point depression ST elevation from Early Repolarization, and J-point depression Approach to Pediatric ECG

Step 5: Specific Waveforms Approach to Pediatric ECG 3 days old 12 years old

Normal Adult ECG

Step 5: Specific Waveforms Approach to Pediatric ECG

Young Adult

2 weeks old

Pediatric ECG findings that may be normal Heart Rate >100 bpm Heart Rate >100 bpm Sinus Arrythmia Sinus Arrythmia QRS Axis >+90° QRS Axis >+90° Shorter intervals (PR, QT, duration of QRS, etc) Shorter intervals (PR, QT, duration of QRS, etc) T-wave inversion of right precordial leads T-wave inversion of right precordial leads Dominant Right precordial R-waves Dominant Right precordial R-waves Q-waves (inferior and lateral leads) Q-waves (inferior and lateral leads) ST elevation due to early repolarization ST elevation due to early repolarization