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

2 week male with ?Apparent Life Threatening Event

Inverted T waves in V1

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)

Normal Findings Q waves

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

Q waves in inferior/lat leads

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

8 year old boy referred for an irregular heart rhythm

Sinus rhythm Varied heart rate

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*

11 year old male with chest pain

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

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

Now for some abnormal ECG’s

3-year-old girl referred with systolic murmur

rsR’ in V1

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

8 week male with tachypnea

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

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

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

9 year old male with loud systolic murmur at LUSB

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

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

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)

4-month-old infant with wheezing and cardiomegaly

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

ALCAPA Anomalous Left Coronary Artery from the Pulmonary Artery

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

Summary 1.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

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

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

Table of LVH/RVH criteria

Table of Normals

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)

Other Pearls PR interval short at birth ( ), 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