Erich C Maul DO FAAPErich C. Maul, DO, FAAPPediatric Hospitalist

Chief Moron in Residence

Kentucky Children’s Hospital

ObjectivesObjectivesObjectivesObjectives

Review basic EKG physiologyReview basic EKG physiology Discuss age related changes to EKGsDiscuss age related changes to EKGs Discuss age related changes to EKGsDiscuss age related changes to EKGs Present a basic, reliable system for Present a basic, reliable system for

EKG review and interpretationEKG review and interpretationEKG review and interpretationEKG review and interpretation Not make you a cardiologist, but an Not make you a cardiologist, but an

t t li i i h it t li i i h iastute clinician who recognizes astute clinician who recognizes abnormal from normalabnormal from normal

What is an EKG?What is an EKG?What is an EKG?What is an EKG?

Graphic representation of the Graphic representation of the progression of electrical activity of the progression of electrical activity of the heartheart

Many times a poor screening test, but Many times a poor screening test, but it’s quick, nonit’s quick, non--invasive and cheapinvasive and cheap–– And if you interpret it, you can bill for it And if you interpret it, you can bill for it

d k $d k $and make $and make $–– May help with diagnosis ~20% of the May help with diagnosis ~20% of the

timetimetimetime

Laws of EKG’s I learned in Laws of EKG’s I learned in Physics…but just never knew itPhysics…but just never knew it

Do I really need to know this?Do I really need to know this?Do I really need to know this?Do I really need to know this?

Lead V1 fourth intercostal space just right of thesternum.

Lead V fourth intercostal space just left of theLead V2 fourth intercostal space just left of the sternum.

Lead V3 midway between leads V2 and V4.Lead V4 midclavicular line in the fifth interspace.Lead V anterior axillary line at same level asLead V5 anterior axillary line at same level as

lead V4.Lead V6 midaxillary line at same level as lead V4

StandardizationStandardizationStandardizationStandardization

Can change the gainCan change the gain–– Change amplitude of complexesChange amplitude of complexes–– Normal is 10mm/mVNormal is 10mm/mV–– Common variant is 10Common variant is 10--5mm/mV5mm/mV

Can change the speedCan change the speed–– Normal is 25mm/secNormal is 25mm/sec

Why 12 leads?Why 12 leads?Why 12 leads?Why 12 leads?

History essentially, but can modify if History essentially, but can modify if neededneeded–– Right sided leadsRight sided leads

Allows for using 2Allows for using 2--D technology andD technology and Allows for using 2Allows for using 2 D technology and D technology and our innate smarts to get a 3our innate smarts to get a 3--D image D image of the heartof the heartof the heartof the heart–– Think of each lead as a camera looking at Think of each lead as a camera looking at

the heart from that specific anglethe heart from that specific anglethe heart from that specific anglethe heart from that specific angle

When do you get them?When do you get them?When do you get them?When do you get them?

Bedside monitoringBedside monitoring Suspicion ofSuspicion of Suspicion of…Suspicion of…

–– Arrhythmia/conduction anomalyArrhythmia/conduction anomalyCongenital heart diseaseCongenital heart disease–– Congenital heart diseaseCongenital heart disease

–– Acquired heart diseaseAcquired heart disease

P i t d th i iti tiP i t d th i iti ti Prior to drug therapy initiationPrior to drug therapy initiation

Interpretation of EKG’sInterpretation of EKG’sInterpretation of EKG sInterpretation of EKG s

Need a systemNeed a system Need a methodNeed a method Need a drink…Need a drink… How you interpret depends on theHow you interpret depends on the How you interpret depends on the How you interpret depends on the

situation you are insituation you are in–– Acutely ill in PICUAcutely ill in PICU--pattern recognitionpattern recognitionAcutely ill in PICUAcutely ill in PICU pattern recognitionpattern recognition–– Stable in clinic/ED/wardStable in clinic/ED/ward--scalar or vector scalar or vector

approachapproach

Methods of interpretationMethods of interpretationMethods of interpretationMethods of interpretation

Pattern recognitionPattern recognition–– What you learn in PALS/ACLSWhat you learn in PALS/ACLS

R d dR d d–– Read and reactRead and react VectorVector

–– EKG with magnitude and directionEKG with magnitude and direction–– EKG with magnitude and directionEKG with magnitude and direction–– Easier than it soundsEasier than it sounds

ScalarScalar–– EKG lead with magnitude onlyEKG lead with magnitude only–– Can make a vector using 2 different scalar leadsCan make a vector using 2 different scalar leads

Pattern recognitionPattern recognitionPattern recognitionPattern recognition

Know them for lifeKnow them for life--threatening threatening situations so you an intervene situations so you an intervene appropriatelyappropriately

MethodMethod–– Sinus or notSinus or not–– Fast or slowFast or slow–– QRS wide or narrowQRS wide or narrow–– Stable or unstableStable or unstable

The more stable kidThe more stable kidThe more stable kidThe more stable kid

AgeAge RateRate

Intervals and wavesIntervals and waves–– P, QRS, TP, QRS, T

PR ST QT/QTcPR ST QT/QTc RhythmRhythm AxisAxis

P QRS TP QRS T

–– PR, ST, QT/QTcPR, ST, QT/QTc–– R wave progressionR wave progression

Hypertrophy or Hypertrophy or –– P, QRS, TP, QRS, T yp p yyp p yenlargementenlargement–– AtrialAtrial–– VentricularVentricular–– VentricularVentricular

Conduction disturbanceConduction disturbance

Are you suicidal?Are you suicidal?yyOnly reading EKG’s.Only reading EKG’s.

How are you to remember all these How are you to remember all these age appropriate norms?age appropriate norms?

LOOK THEM UP IN HARRIET LANE!LOOK THEM UP IN HARRIET LANE! When evaluating an EKG, go to the When evaluating an EKG, go to the g , gg , g

Cardiology chapter and look at the Cardiology chapter and look at the EKG section…it is scarily similar to my EKG section…it is scarily similar to my talktalk–– Guess how my mentors taught me EKG’sGuess how my mentors taught me EKG’s

Biggest TakeBiggest Take home Pointhome PointBiggest TakeBiggest Take--home Pointhome Point

NeverNever read an EKG in isolationread an EKG in isolation–– Always do it as related to a clinical caseAlways do it as related to a clinical caseAlways do it as related to a clinical case Always do it as related to a clinical case

or in relation to the reason you got it.or in relation to the reason you got it.–– The clinical background is very importantThe clinical background is very importantg y pg y p

AgeAgeAgeAge

EKG’s vary greatly with ageEKG’s vary greatly with age NewbornsNewborns NewbornsNewborns

–– Right sided dominance of forcesRight sided dominance of forces

Adult EKG form by age 3 y/o withAdult EKG form by age 3 y/o with Adult EKG form by age 3 y/o, with Adult EKG form by age 3 y/o, with most changes occurring by 3most changes occurring by 3--6 months6 months

RateRateRateRate

60/RR interval=rate 60/RR interval=rate Count # of RR’s in 6 large divisions andCount # of RR’s in 6 large divisions and Count # of RR s in 6 large divisions and Count # of RR s in 6 large divisions and

multiply by 50multiply by 50 Read the machine!Read the machine! Read the machine!Read the machine!

RhythmRhythmRhythmRhythm

SinusSinus–– P wave before every QRSP wave before every QRSP wave before every QRSP wave before every QRS–– Normal PR interval for ageNormal PR interval for age–– Normal P wave axisNormal P wave axisNormal P wave axisNormal P wave axis

Upright I and aVFUpright I and aVF

NonNon--sinussinus NonNon sinussinus

AxisAxisAxisAxis

Determine quadrant at a minimumDetermine quadrant at a minimum Determine quadrant at a minimumDetermine quadrant at a minimum Successive approximation to fine tune axisSuccessive approximation to fine tune axis

U l d I d VFU l d I d VF Use leads I and aVFUse leads I and aVF

Successive ApproximationSuccessive ApproximationSuccessive ApproximationSuccessive Approximation

Find the axis quadrantFind the axis quadrant Look for limb lead that is biphasicLook for limb lead that is biphasic Look for limb lead that is biphasicLook for limb lead that is biphasic

–– Or close to biphasicOr close to biphasic

Axis is perpendicular to the biphasicAxis is perpendicular to the biphasic Axis is perpendicular to the biphasic Axis is perpendicular to the biphasic leadlead

Successive ApproximationSuccessive Approximationpppp

1.1. Find quadrantFind quadrantFi d bi h i li b l d i iFi d bi h i li b l d i i2.2. Find biphasic limb lead; axis is Find biphasic limb lead; axis is perpendicular to that leadperpendicular to that lead

P wave and T wave axisP wave and T wave axisP wave and T wave axisP wave and T wave axis

Find by same methodFind by same method Both should be between 0Both should be between 0--9090 Both should be between 0Both should be between 0 9090 ANY T wave axis outside of 0ANY T wave axis outside of 0--90 is 90 is

abnormalabnormalabnormalabnormal–– Ventricular strain, conduction Ventricular strain, conduction

disturbances metabolic or ischemicdisturbances metabolic or ischemicdisturbances, metabolic or ischemic disturbances, metabolic or ischemic dysfunctiondysfunction

Intervals and wavesIntervals and wavesIntervals and wavesIntervals and waves

Measure against Measure against age appropriate age appropriate normsnormsnormsnorms

Use RR intervalUse RR interval Use RR interval Use RR interval preceding the QT preceding the QT you measureyou measure

P waves T waves ST oh my!P waves T waves ST oh my!P waves, T waves, ST, oh my!P waves, T waves, ST, oh my!

QRS wavesQRS wavesQRS wavesQRS waves

Atrial HypertrophyAtrial HypertrophyAtrial HypertrophyAtrial Hypertrophy

RAHRAH–– pp--pulmonalepulmonale

P>3mmP>3mm–– P>3mmP>3mm–– II, V1, V2II, V1, V2

LAHLAH–– pp--mitralemitrale–– P duration >0.1sP duration >0.1s–– Any leadAny lead–– Any leadAny lead

BAHBAH–– Combination of bothCombination of both

Ventricular HypertrophyVentricular HypertrophyVentricular HypertrophyVentricular HypertrophyGuiding PrinciplesGuiding Principles

QRS axis usually directed toward QRS axis usually directed toward hypertrophied ventriclehypertrophied ventricleQRS l i d di i fQRS l i d di i f QRS voltages increase toward direction of QRS voltages increase toward direction of involved ventricleinvolved ventricle

R/S ratio changes according to the ventricleR/S ratio changes according to the ventricle R/S ratio changes according to the ventricle R/S ratio changes according to the ventricle that is hypertrophiedthat is hypertrophied

Severe hypertrophy may yield T wave axisSevere hypertrophy may yield T wave axisSevere hypertrophy may yield T wave axis Severe hypertrophy may yield T wave axis changes (strain)changes (strain)

May slightly increase QRS durationMay slightly increase QRS duration

RVH (outside newborn)RVH (outside newborn)RVH (outside newborn)RVH (outside newborn)

Right axis deviationRight axis deviation R in V1 or S in V6 >98R in V1 or S in V6 >98thth %ile%ile Upright T in V1 after dol 3Upright T in V1 after dol 3 Abnml R/S ratio that favors RVAbnml R/S ratio that favors RV RV strainRV strain Q in V1 (qR or qRs pattern) suggests RVHQ in V1 (qR or qRs pattern) suggests RVH

If l i i f RVH id QRSIf l i i f RVH id QRS TT If voltage criteria for RVH, wide QRSIf voltage criteria for RVH, wide QRS--T T angle with abnml T wave axis indicates angle with abnml T wave axis indicates strain patternstrain patternstrain patternstrain pattern

LVHLVHLVHLVH

Left axis deviationLeft axis deviation R in V6 or S in V1 >98R in V6 or S in V1 >98thth %ile%ile Abnml R/S ratio that favors LVAbnml R/S ratio that favors LV Q in V5 or V6Q in V5 or V6 >>5mm with tall T waves5mm with tall T waves Q in V5 or V6 Q in V5 or V6 >>5mm with tall T waves 5mm with tall T waves

in those leadsin those leads If voltage criteria for LVH a wide QRSIf voltage criteria for LVH a wide QRS-- If voltage criteria for LVH, a wide QRSIf voltage criteria for LVH, a wide QRS

T angle with T axis outside of normal T angle with T axis outside of normal indicates strainindicates strain

Biventricular HypertrophyBiventricular HypertrophyBiventricular HypertrophyBiventricular Hypertrophy

Characteristics of RVH and LVHCharacteristics of RVH and LVH

Ventricular Conduction Ventricular Conduction Disturbances (VCD)Disturbances (VCD)

Abnormally prolonged QRS durationAbnormally prolonged QRS duration–– RBBBRBBB–– LBBBLBBB–– PrePre--excitiationexcitiation–– PacemakersPacemakers--look for pacing spikelook for pacing spikePacemakersPacemakers look for pacing spikelook for pacing spike

CANNOT diagnose hypertrophy if a BBB is presentCANNOT diagnose hypertrophy if a BBB is present

RBBBRBBBRBBBRBBB

Most common VCD in pedsMost common VCD in peds–– After open heart surgeryAfter open heart surgery–– Lesions with RV volume overload (ASD)Lesions with RV volume overload (ASD)Lesions with RV volume overload (ASD)Lesions with RV volume overload (ASD)–– CHD such as Ebstein’s anomaly and CoACHD such as Ebstein’s anomaly and CoA–– Cardiomyopathy, myocarditis, CHF, muscle diseases Cardiomyopathy, myocarditis, CHF, muscle diseases

(DMD), Kearns(DMD), Kearns--Sayre syndrome, Brugada syndrome,Sayre syndrome, Brugada syndrome,(DMD), Kearns(DMD), Kearns Sayre syndrome, Brugada syndrome, Sayre syndrome, Brugada syndrome, Arrhythmogenic RV dysplasia, congenital hereditary RBBB Arrhythmogenic RV dysplasia, congenital hereditary RBBB (Chro19)(Chro19)

RBBB CriteriaRBBB CriteriaRBBB CriteriaRBBB Criteria

Right axis deviationRight axis deviation Prolonged QRS for ageProlonged QRS for age Prolonged QRS for ageProlonged QRS for age Terminal slurring of QRSTerminal slurring of QRS

Wid l d S i I V5 V6Wid l d S i I V5 V6–– Wide slurred S in I, V5, V6Wide slurred S in I, V5, V6–– Terminal slurred R’ in aVR, V4R, V1, V2Terminal slurred R’ in aVR, V4R, V1, V2

ST depression and T wave inversionST depression and T wave inversion–– (adults)(adults)

LBBBLBBBLBBBLBBB

Common in adults due to HTN and Common in adults due to HTN and ischemia, but rare in kidsischemia, but rare in kids,,

Usually result ofUsually result of–– SurgerySurgery--Ao valve replacementAo valve replacement–– SurgerySurgery--Ao valve replacement, Ao valve replacement,

ventriculotomy, septal myomectomy, ventriculotomy, septal myomectomy, LVOT proceduresLVOT procedurespp

–– Hypertrophic cardiomyopathyHypertrophic cardiomyopathy–– MyocarditisMyocarditisMyocarditisMyocarditis

LBBB CriteriaLBBB CriteriaLBBB CriteriaLBBB Criteria

Left axis deviationLeft axis deviation Prolonged QRS for ageProlonged QRS for age Loss of Q in V5 and V6Loss of Q in V5 and V6 QS pattern in V1QS pattern in V1 Slurred QRSSlurred QRS

–– Slurred, wide R in I aVL, V5, V6Slurred, wide R in I aVL, V5, V6Wide s in V1 V2Wide s in V1 V2–– Wide s in V1, V2Wide s in V1, V2

ST depression and T wave inversion in V4ST depression and T wave inversion in V4--V6V666

Moron Moment…Moron Moment…is it a VCD or Hypertrophy?is it a VCD or Hypertrophy?

PrePre excitationexcitationPrePre--excitationexcitation

Accelerated AV conduction to one ventricle Accelerated AV conduction to one ventricle via an accessory pathwayvia an accessory pathway

Classic examplesClassic examples–– Wolff Parkinson WhiteWolff Parkinson White–– Lown Ganong Levine syndromeLown Ganong Levine syndrome

Short PR, normal QRSShort PR, normal QRS

Anomalous nodoventricular connectionsAnomalous nodoventricular connections–– Anomalous nodoventricular connectionsAnomalous nodoventricular connections Mahaim fibersMahaim fibers Normal PR, long QRS with delta waveNormal PR, long QRS with delta wave

WPWWPWWPWWPW

Kent bundle conducts faster than the Kent bundle conducts faster than the AV node (normal conduction delay)AV node (normal conduction delay)( y)( y)

Ventricle depolarizes, but at a slower Ventricle depolarizes, but at a slower rate than Hisrate than His--Purkinje systemPurkinje systemrate than Hisrate than His Purkinje systemPurkinje system–– Delta waveDelta wave

If AV node impulse conducts the QRSIf AV node impulse conducts the QRS If AV node impulse conducts, the QRS If AV node impulse conducts, the QRS becomes characteristic of WPWbecomes characteristic of WPW

WPW CriteriaWPW CriteriaWPW CriteriaWPW Criteria

Short PR interval Short PR interval for agefor age Delta waveDelta wave Delta waveDelta wave Wide QRS Wide QRS for agefor age

D ’t b t d lt l itD ’t b t d lt l it Don’t worry about delta wave polarity Don’t worry about delta wave polarity or type A or B, let Electrophysiologist or type A or B, let Electrophysiologist fi it tfi it tfigure it outfigure it out

What’s the big deal about What’s the big deal about ggWPW?WPW? Prone to attacks of SVTProne to attacks of SVT

–– Tachycardia masks the delta wave because of a Tachycardia masks the delta wave because of a rere--entrant pathwayentrant pathway

PrePre--excitation can mimic ventricular excitation can mimic ventricular h t hi d BBB th k thh t hi d BBB th k thhypertrophies and BBB; you then make the hypertrophies and BBB; you then make the wrong diagnosiswrong diagnosisCan be associated with congenital heartCan be associated with congenital heart Can be associated with congenital heart Can be associated with congenital heart diseasedisease–– Ebstein’s anomaly glycogen storage dzEbstein’s anomaly glycogen storage dzEbstein s anomaly, glycogen storage dzEbstein s anomaly, glycogen storage dz

SummarySummarySummarySummary

Have a system and a reliable Have a system and a reliable peripheral brainperipheral brainp pp p

Understand age appropriate normal Understand age appropriate normal from abnormalfrom abnormalfrom abnormalfrom abnormal

Never interpret the EKG in isolationNever interpret the EKG in isolation

ReferencesReferencesReferencesReferences

Park MK. 2003. Pediatric Cardiology Handbook, 3Park MK. 2003. Pediatric Cardiology Handbook, 3rdrd edition, Mosby, edition, Mosby, Philadelphia.Philadelphia.

Park MK. 2008. Pediatric Cardiology for Practitioners, 5Park MK. 2008. Pediatric Cardiology for Practitioners, 5thth edition, Mosby edition, Mosby Elsevier PhiladelphiaElsevier PhiladelphiaElsevier, Philadelphia.Elsevier, Philadelphia.

Park MK. and Guntherroth WG. 2006. How to Read Pediatric ECGs, 4Park MK. and Guntherroth WG. 2006. How to Read Pediatric ECGs, 4thth

edition, Mosby Elsevier, Philadelphia.edition, Mosby Elsevier, Philadelphia. Deal BJ, Johnsrude CL, Buck SH. 2004. Pediatric ECG Interpretation An Deal BJ, Johnsrude CL, Buck SH. 2004. Pediatric ECG Interpretation An

Illustrative Guide, Futura BlackwellIllustrative Guide, Futura Blackwell Goldberger AL. 2006. Clinical Electrocardiography, a Simplified Approach, 7Goldberger AL. 2006. Clinical Electrocardiography, a Simplified Approach, 7thth

edition, Mosby Elsevier, Philadelphia.edition, Mosby Elsevier, Philadelphia.

Figure 1: 1-day-old infant, PCP got EKG because he h d t 2 h l f di ll iheard a murmur at 2 hol; feeding well, no cyanosis, no tachypnea

Figure 2: 5-month-old female, family history of LQTc syndrome

Figure 3: Asymptomatic 8-year-old female, “the voices” told her mom that her child was going to die of Sudden Cardiac Death

Figure 4: 8-year-old boy referred to ED for irregular heart rhythm in PCP’s office, you are consulted for admission with telemetry

Figure 5: Asymptomatic 14-year-old female, local psychiatrist wants to start TCA for depression

Figure 6: 3-week-old infant with chronic lung disease and a murmur at LUSB

Figure 7: 16-year-old girl with tricuspid atresia status post Fontan procedure, acute onset of chest pain without dyspnea

Figure 8: 7-month-old infant with loud systolic murmur at left upper sternal border

Figure 9: 5-year-old girl with systolic murmur at right upper sternal border

Figure 10: 13-year-old boy with exertional chest pain

Figure 11: 13-year-old boy status post repair of ventricular septal defect

Figure 12: 13-year-old boy with family history hypertrophic cardiomyopathy

Figure 13: 12 year old boy with syncope during a baseball game youFigure 13: 12-year-old boy with syncope during a baseball game, you see him in the office 2 days after ER discharge; EKG is “normal” per ER read. You don’t have a copy, so you get one in your office…

Figure 14: 11-year-old with surgical complete heart block, dual-chamber pacemaker who comes to your office feeling

weak and fatigued