Pediatric ECG’s Christine Kennedy EM Rounds May 20, 2010.
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Transcript of Pediatric ECG’s Christine Kennedy EM Rounds May 20, 2010.
![Page 1: Pediatric ECG’s Christine Kennedy EM Rounds May 20, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022081520/5697bfa81a28abf838c9963e/html5/thumbnails/1.jpg)
Pediatric ECG’s
Christine Kennedy
EM Rounds
May 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– Should be 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 #2Q 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 #3Sinus 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 #4ST elevation
• Early Repolarization– Normal Variant, common in adolescents– ST elevation <25% of T wave height– Symmetric T waves
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Now for some abnormal ECG’s
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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 #5RSR’
• 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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Axis +130
Pure R in V1
S in V6>4 mm
Pulmonary Stenosis
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Take home point #7RVH
• 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 #8ST 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 V1 between 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 <25% of T wave height
5. RSR’• If R’>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), increases with increasing muscle mass
• QRS shorter – Abnormal If >0.08 in children <8 years
• LVH– LV strain in V5&V6 (flipped T’s), mature precordial R
wave progression in newborn
• Sinus tachycardia– When febrile, expect HR to increase by 10 for every
degree elevation in temperature