Pediatric ECG:A practical Approach

Dr ANIL S.R

Consultant Pediatric Cardiologist MIMS Calicut

• A wriggling neonate• A crying infant• An apprehensive child• A ticklish adolescent

ECG in pediatric Practice

• Evolution of ECG- Neonate to Adolescent• Identify an abnormal ECG at a given age• ECG and Common congenital heart diseases• ECG abnormalities after surgical interventions• Pediatric arrhythmias

ECG in pediatric Practice

Normal neonate

Normal infant

Low voltages of QRS in precordial and limb leads

Low T wave voltages

RV dominance

Right Axis deviation of upto 180 degree

Upright T waves in right precordial leads- Ist week of life

Normal Child

Normal adolescent

Age related changes

• HR decreases• All durations and intervals increases• RV dominance gradually changes to LV

dominance• QRS axis- less rightward shift• R wave in RPLs decreases and in LPLs

it increases. This is reverse for S wave

LV/RV Mass ratio

30w 1.2:1

33w 1:1

Birth 0.8:1

6m 2:1

Adult 2.5:1

Preterm infants

Low voltages of QRS

Low T wave voltages

Less RV dominance

Left Axis deviation

Short PR, QRS and QT intervals

More ECG variability

Leads

Bipolar leads : I , II, IIIUnipolar leads : aVR, aVL, aVF V1 to V6

LEADS: Bipolar leads : I , II, III

Lead I

Lead II Lead III

LARA

LL

• Selected by Einthoven• Records PD between two

points• Rt leg electrode- ground

wire• II = 1 + 111 (Kirchoff’s Law)

Laws of ECG

• Depolarization is towards the +ve of a lead= +Ve Deflection

• Depolarization is towards the -ve of a lead= -Ve Deflection

• Depolarization is perpendicular to the lead= Biphasic or No Deflection

Right atrial Enlargement

Left atrial Enlargement

Right Ventricular Hypertrophy

Left Ventricular Hypertrophy

Common congenital heart defects

Left to right shuntsStenotic lesions

Cyanotic heart diseases

Secundum ASD

Primum ASD.... Left axis deviation and Q in aVL

Sinus venosus ASD ... Note inverted P waves in III

Small VSD in a young child ..... No LV forces

Large VSD with biventricular forces ....... Note Katz Wachtel phenomenon

VSD Eisenmenger......note loss of q wave in V6

Large Inlet VSD, ......note left axis

PDA ... Note prominent LV forces

PDA in Rubella syndrome patients

Left axis deviation due to injury to conduction tissues

AS with LVH, note strain pattern

AS with significant LVH and strain pattern

Coarctation in infancy ..... Since PAH is common, RV forces are dominant

Coarctation

• In infancy, due to pulmonary hypertension, Right axis and RVH are common

• In older patients, LVH occurs

Coarctation in an older child

Valvar PS

Sick TOF

TOF - Transition occurs in V1Importance of right chest leads

D-TGA in a older child

Corrected TGA with large VSD.......Note septal Q in right sided leads, no Q in V6

Common atrium.....mimics a primum ASD, but patient is blue

Ebstein’s anomaly of tricuspid valve....... Striking RA forces, splintered qrs in V1

TAPVC

TAPVC ... ECG shows features of PAH

Tricuspid atresia..... Left axis and LV forces

Pulmonary atresia, Intact IVS..... Again LV forces but axis is not leftward

Single ventricle - RAD with LV forces

In a cyanotic child:• Right ventricular forces: TOF

TOF with pulmonary atresiaTGATAPVC, Common atrium

• Left ventricular forces:Tricuspid atresiaPulmonary atresia with

IVSHypoplastic right heartSingle ventricleEbsteins

• Bi-ventricular forces: TruncusDORV

• Normal ECG: Pulmonary AV fistula Anomalous systemic venous return

Provides valuable clues in diagnosis

Invaluable in arrhythmia

Comprehensive assessment before surgery

Read and analyze ECGs

Conclusion