ECG Rounds May 201
Transcript of ECG Rounds May 201
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Pediatric ECGs
Christine Kennedy
EM RoundsMay 20, 2010
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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)
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Normal Findings
T waves
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2 week male with ?Apparent Life Threatening Event
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Inverted T waves in V1
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Take home point #1
T waves
Newborn (week 1):
may be either inverted or upright in V1
Between 8 days & 8 years
Shouldbe inverted in V1(if not = RVH)
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Normal Findings
Q waves
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1-year-old male, asymptomatic,
Mom told that child has a murmur
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Q waves in inferior/lat leads
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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
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8 year old boy referred for an irregular heart rhythm
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Sinus rhythm
Varied heart rate
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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*
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11 year old male with chest pain
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Sinus rhythm, rate 60
ST elevation I, II, V2-6
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Take home point #4
ST elevation
Early Repolarization
Normal Variant, common in adolescents
ST elevation
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Now for some abnormal ECGs
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3-year-old girl referred with systolic murmur
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rsR in V1
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Take home point #5
RSR
If R>R in V1
Suspect RVH
25% chance of having ASD
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8 week male with tachypnea
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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
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Left axis deviation
RVH: S in V6 >10 [0-10]
LVH: R in V6 >21 [5-21]
AVSD
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Take home point #6
Left Axis Deviation
LAD in first couple of months: suspect
AVSD
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9 year old male with loud systolic murmur at LUSB
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Axis +130
Pure R in V1
S in V6>4 mm
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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)
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4-month-old infant with wheezing and cardiomegaly
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ST elevation in V1-3, 5, V3R, V4R
Inverted T waves in V5-6
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ALCAPAAnomalous Left Coronary Artery
from the Pulmonary Artery
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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
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Summary
1. T waves Should be inverted in V1between 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
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Summary
4. Early Repolarization Normal Variant, common in adolescents
ST elevation R in V1, suspect RVH
25% chance of having ASD
6. Left axis deviation If present in first couple of months: suspect AVSD
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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
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Table of LVH/RVH criteria
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Table of Normals
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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).
195-208.
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Other Pearls
PR interval short at birth (0.08-0.15), increaseswith increasing muscle mass
QRS shorter Abnormal If >0.08 in children