Introduction to Pediatric ECGs

Thomas R. Burklow, MD Asst C, Pediatric Cardiology Walter Reed Army Medical Center

Pediatric ECGs

Electrophysiology and Anatomy

SA Node

Pediatric ECGs

Mechanics of tracing
Small box = 1 x 1 mm Large box = 5 x 5 mm Paper speed (horizontal boxes)

Standard = 25 mm/sec

Voltage calibration (vertical boxes)

Standard = 10 mm/mV (2 big boxes) Half standard = 5 mm/mV (1 big box) May have 10/5: standard for chest leads, half-standard for precordial leads NOTE THE CALIBRATION!!
Pediatric ECGs

ECG basics: grid paper

Pediatric ECGs

Basic electrocardiogram

Pediatric ECGs

Interpretation

Be systematic!!

Rhythm Rate Axis Intervals Atrial enlargement Ventricular hypertrophy ST/T wave evaluation
Pediatric ECGs

Rhythm
Sinus rhythm Subsidiary pacemaker Tachyarrhythmia Bradyarrhythmia Atrioventricular block

Pediatric ECGs

Normal sinus rhythm

P wave before every QRS QRS following every P wave Normal P wave axis Normal PR interval is NOT required

Pediatric ECGs

P wave axis

Atrial depolarization occurs from SA node

Wave passes right to left, top to bottom Positive deflections in leads I (right to left) and aVF (top to bottom) Normal P wave axis = 0-90 degrees Coronary sinus or low right atrial rhythm is common benign finding, especially in teens Positive in lead I, negative in aVF
Pediatric ECGs

Abnormal axis implies ectopic pacemaker

Rate
Measured in beats per minute 60 / RR interval (in seconds) 300 / number of big boxes between consecutive QRS complexes 1500 / number of little boxes between consecutive QRS complexes

Pediatric ECGs

Heart rate
Known

time interval

Beats in 6 seconds (30 big boxes) x 10 Beats in 3 seconds (15 big boxes) x 20

Pediatric ECGs

Heart rate
Rate

approximation

Rate estimate: 300 - 150 - 75 - 60 - 50 Easy to memorize No calculator needed

Pediatric ECGs

Normal resting heart rates

Newborn: 2 years: 4 years: > 6 years: Adult:

110 - 150 bpm 85 - 125 bpm 75 - 115 bpm 60 - 100 bpm 50 - 100 bpm

Pediatric ECGs

Axis

Hexaxial reference system

Bipolar limb leads

I, II, III aVR, aVL, aVF

Augmented unipolar leads

Horizontal reference system

Precordial leads

V1 - V7 Right sided leads (e.g. rV3)

Pediatric ECGs

Reference systems

Pediatric ECGs

Axis determination

Successive approximation

Locate quadrant with leads I and aVF Narrow down by using leads within quadrant Use most equiphasic lead Axis is perpendicular to that lead, in the quadrant previously identified

Equal amplitudes

If two leads with equal net QRS amplitudes exist, the mean axis lies midway between the axis of these two leads

Pediatric ECGs

Quadrant determination
Normal axis

Left axis Boston

Right axis Extreme R/L axis Seattle
Pediatric ECGs

Successive approximation

Pediatric ECGs

Axis determination

Amplitude vector

Add net R-S in lead I, R-S in aVF Plot in mm on grid (lead I horizontal, lead aVF vertical) Draw vector from origin to net amplitude Angle of vector = axis

Pediatric ECGs

Right axis deviation

Axis > 100 degrees Normal for age: rightward axis > 100 degrees, but within normal limits for age (e.g. 2 week old with axis of +140) Suggestive of RVH

Pediatric ECGs

Left axis deviation

Axis < -5 degrees Q waves in leads I and aVL Conduction abnormality Associated with atrioventricular septal defect No correlation with LVH Occurs in 5% of normal population

Pediatric ECGs

Causes of left axis deviation

Normal variant AV septal defect (including primum ASD) Perimembranous inlet VSD Tricuspid atresia Single ventricle Double outlet right ventricle Noonan syndrome Left anterior hemiblock after MI
Pediatric ECGs

PR Interval
Onset of atrial contraction to onset of ventricular contraction (measures cumulative time of depolarization through atria, AV node, and His-Purkinje system) Varies between leads Increases with age Decreases with heart rate

Pediatric ECGs

Long PR interval

= First degree AV block

Drugs Atrial surgery (scar tissue) Acute rheumatic fever (minor Jones criteria) Kawasaki disease

Pediatric ECGs

Short PR interval

Etiologies

Wolff-Parkinson-White Glycogen storage disease type IIa (Pompes) Fabry disease GM1 gangliosidosis Friedrichs ataxia Duchennes muscular dystrophy

Pediatric ECGs

QRS Duration
Beginning of Q wave to end of S wave Use a lead where a Q wave is visible Normal = 0.04 - 0.08 (may be up to 0.09 in adolescents) > 0.12 = bundle branch block 0.10-0.12: evaluate morphology

Pediatric ECGs

RSR Morphology
Seen in right precordial leads: V1, rV3 Common: occurs in 7% of kids R and R both small and of short duration S wave larger than R and R R is less than 10 mm (15 mm in infants) Abnormal RSR may reflect RBBB or RVH (volume overload type)

Pediatric ECGs

QT Interval

Onset of ventricular depolarization (Q wave) to end of ventricular repolarization (T wave) Do NOT include U waves Varies inversely with heart rate Best leads: II, V5, V6 QTC (Bazetts formula) = QT/square root RR

Normal < 0.44 sec May be as high as 0.45 sec in adol/adult females May be as high as 0.49 sec in newborns (to 6 mo.)

QT ruler
Pediatric ECGs

QT Abnormalities

Short QT

Long QT - Acquired

Digoxin Hypercalcemia

Metabolic

Hypocalcemia Hypomagnesemia Malnutrition (anorexia) Ia and III antiarrhythmics Phenothiazines TCA

Long QT - Congenital

Drugs

Jervell-Lange-Nielsen

AR, deafness

Romano-Ward

AD, normal hearing

CNS trauma Myocardial

Ischemia Myocarditis

Pediatric ECGs

Atrial enlargement

Right atrial enlargement

Left atrial enlargement

P wave amplitude > 2.5 mm in II Deep negative deflection in first 0.04 seconds in chest leads

Terminal portion of P wave Negative deflection in V1 beyond 0.04 sec Duration of negative deflection > 0.04 sec Total duration > 0.10 sec

Pediatric ECGs

Atrial enlargement

Pediatric ECGs

Right ventricular hypertrophy

Mild

R > 15 mm (< 1 year) or > 10 mm (> 1 year) Abnormal RSR of normal to slightly prolonged duration in right chest leads Definite right axis deviation (non-RBBB) rR or pure R in right chest leads Significant S in left chest leads
Pediatric ECGs

Moderate

Right ventricular hypertrophy

Severe

Marked RAD qR pattern V3R or V1 Tall pure R wave > 15 mm (any age) in right chest Upright T wave > 3-5 days of age Very tall R wave with ST depression and T wave inversion in V1 (strain) Deep S wave V6
Pediatric ECGs

Left ventricular hypertrophy

Criteria

LAD for age (more useful in neonates/infants) R in V5/V6 or I, II, III, aVF, aVL above normal S in V1/V2 above normal Abnormal R/S ratio (R/S in V1/V2 below normal) Deep/wide q wave in V5/V6 above fmm

Tall symmetric T waves = LV diastolic overload

Pediatric ECGs

With LVH, inverted T waves in I/aVF = strain

Combined ventricular hypertrophy

Criteria

Positive voltage criteria for LVH and RVH

In absence of BBB, preexcitation

Positive voltage criteria for LVH or RVH with relatively large voltages for the other ventricle Large equiphasic QRS complexes in > 2 limb leads and midprecordial (V2 - V5) leads

Katz-Wachtel phenomenon

Pediatric ECGs

QRS morphologies

Normal

RBBB

Preexcitation IV block (delta wave)

Pediatric ECGs

Conduction disturbances: RBBB

Prolongation in terminal phase of QRS (terminal slurring Delayed conduction through RBB prolongs depolarization of RV Slurring is to the right and anterior

RAD QRS above ULN for age Wide/slurred S in I, V5, V6 Terminal slurred R in aVR and V1, V2, V3r ST segment shift, T wave inversion (in adults)

Pediatric ECGs

RBBB

Bundle branch block

RBBB: Etiologies

ASD/PAPVR Right ventriculotomy Ebsteins Coarctation (< 6 months) Rare in children Seen in adults with ischemic and hypertensive heart disease
Pediatric ECGs

LBBB

Intraventricular block
Slowing

throughout QRS complex Etiologies

Metabolic disorders (hyperkalemia) Myocardial ischemia (CPR, quinidine toxicity) Diffuse myocardial disease

Pediatric ECGs

Wolff-Parkinson-White
Preexcitation:

initial slurring of QRS Accessory conduction pathway

Premature depolarization of part of the myocardium Slow conduction delta wave Short PR interval for age Delta wave Wide QRS for age
Pediatric ECGs

Criteria:

Preexcitation syndromes

Lown-Ganong-Levine

Short PR interval Normal QRS duration Fibers bypass upper AV node, but conduct normally Normal PR interval Long QRS duration Delta wave Fiber bypasses His bundle, enters RV myocardium
Pediatric ECGs

Mahaim fiber