1. Approach to Pediatric ECG September 22, 2005 Sultana Qureshi

2. 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

3. 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

4. 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° - 100 ° QRS Axis 10° - 100 ° Pulmonary vascular resistance Systemic Vascular Resistance

5. Step 1: Identify AGE! Approach to Pediatric ECG

6. Step 2: Heart Rate Approach to Pediatric ECG TABLE 164-2 -- Age-Specific Rates Age Beats per minute Range (degrees)Mean First week100–175130 1 week to 3 months85–190160 3–12 months110–180140 1–3 years98–163126 3–5 years65–13298 5–8 years70–11596 8–16 years55–10779 Rosen (2005)

7. Step 2: Heart Rate Approach to Pediatric ECG

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

9. 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

10. 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 week90-16060-1800.08-0.150.03-0.085-260-230-120-10 1-3wks100-18045-1600.08-0.150.03-0.083-210-162-160-10 1-2 mo120-18030-1350.08-0.150.03-0.083-180-155-210-10 3-5 mo105-1850-1350.08-0.150.03-0.083-200-156-220-10 6-11 mo110-1700-1350.07-0.160.03-0.082-200.5-206-230-7 1-2 yr90-1650-1100.08-0.160.03-0.082-180.5-216-230-7 3-4 yr70-1400-1100.09-0.170.04-0.081-180.5-214-240-5 5-7 yr65-1400-1100.09-0.170.04-0.080.5-140.5-244-260-4 8-11 yr60-130-15-1100.09-0.170.04-0.090-140.5-254-250-4 12-15 yr65-130-15-1100.09-0.180.04-0.090-140.5-214-250-4 > 16 yr50-120-15-1100.12-0.200.05-0.100-140.5-234-210-4

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

12. Step 4: QRS Axis Approach to Pediatric ECG TABLE 164-5 -- Age-Specific QRS Axis (Frontal Plane) Age Range (degrees) Mean (degree) 1–7 days80–160125 1–4 weeks30–180110 1–3 months10–12570 3–6 months20–8065 6–12 months 0–10065 1–3 years20–10055 3–8 years20–12060

13. 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

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

15. Normal Adult ECG

16. Step 5: Specific Waveforms Approach to Pediatric ECG

17. Young Adult

18. 2 weeks old

19. 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