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    • The Pediatric ECG DR. ATUL KULKARNI MD DR MANDAR HAVAL DCH DNB
    • Objectives Review the cardiac physiology with respect to age, and age related normals Discuss wave morphology and axis as it relates to age and ventricular dominance Review intervals and other “differences” in the pediatric ECG Discuss an approach to interpretation of chamber enlargement Review some basic tachyarrythmias common in children Normal variants and osce on ECG
    • Background ECG changes during the first year of life reflect the switch from fetal to infant circulation, changes in SVR, and the increasing muscle mass of the LV The size of the ventricles changes as the infant grows into childhood and adulthood The RV is larger and thicker at birth because of the physiologic stresses on it during fetal development By approximately 1 month of age, the LV will be slightly larger By 6 months of age, the LV is twice the size of the RV, and by adolescence it is 2.5 times the size
    • Heart rate  Average heart rate peaks at second month of life, then gradually decreases  Resting HRs start at 140 bpm at birth, fall to 120 bpm at 1 year, 100 bpm at 5 years, and adult ranges by 10 years
    • • INTRINSIC HEART RATES Newborn to 3 years: • SA node 95 – 120 • AV node (junctional) 45 – 85 • Purkinje (ventricular) 35 – 55 3 years to teenager • SA node 55 – 120 • AV node (junctional) 35 – 65 • Purkinje (ventricular) 25 ‐ 45
    • Age Related Normal Findings Tables exists that include age based normal ranges for heart rate, QRS axis, PR and QRS intervals, and R and S wave amplitudes After infancy, changes become more subtle and gradual as the ECG becomes more like that of an adult
    • The P Wave Best seen in leads II and V1 P wave amplitude does not change significantly during childhood Amplitudes of 0.025 mV should be regarded as approaching the upper limit of normal
    • The QRS Complex QRS complex duration is shorter, presumable because of decreased muscle mass QRS complexes > 0.08 sec in patients < 8 years is pathologic In older children and adolescence a QRS duration > 0.09 sec is also pathologic
    • The T Wave The T waves are frequently upright throughout the precordium in the first week of life Thereafter, T waves in V1-V3 invert and remain inverted from the newborn period until 8 years of age This is called the “juvenile T wave pattern”, and can sometimes persist into adolescence Upright T waves in the right precordial leads in children can indicate right ventricular hypertrophy
    • 3 day old & 7 y/o
    • QRS Axis and Ventricular Dominance At birth, the axis is markedly rightward (+60 - +160), the R/S ratio is high in V1 and V2 (large precordial R waves), and low in V5 and V6 As the LV muscle mass grows and becomes dominant the axis gradually shifts (+10 - +100) by 1 year of age, and the R wave amplitude decreases in V1 and V2 and increases in V5 and V6
    • What is the axis?
    • What is the axis? LAD Normal RA D Lead I AVF Negative + + _ Lead I AVF Normal Positive Positive RAD Negative Positive LAD Negative Negative
    • What is the axis? RIGHT AXIS DEVEATION
    • What is the axis? LAD
    • What is the axis? NORMAL
    • CHAMBER HYPERTROPHY
    • Interpretation? Right atrial enlargement
    • DIGNOSIS? Left atrial enlargement
    • Atrial Enlargement RAE is diagnosed in the presence of a peaked tall P wave in II In the first 6 months, the P wave must be >3 mm to be pathologic; then >2 mm is abN LAE can be diagnosed with a biphasic P wave in V1 with a terminal inferior component The finding of a notched P wave in II can be a normal variant in 25% of pediatric ECGs
    • Interpretation? Right ventricular hypertrophy (RVH)
    • RVH Large R wave in V1 and large S wave in V6 Upright T wave in V1-V3 RAD Persistent pattern of RV dominance Right Ventricular Hypertrophy Diagnosis depends on age adjusted values for R wave and S wave amplitudes A qR complex or rSR’ pattern in V1 can also be seen Upright T waves in the right precordial leads, RAD, and complete reversal of adult precordial pattern of R and S waves all suggest RVH Lead V1with the R height > 15 mm IN < 1YR & >10mm IN > 1 YR
    • RVH
    • Interpretation? Left ventricular hypertrophy (LVH)
    • LVH R wave > 98th percentile in V6 and S wave > 98th percentile in V1 LV “strain” pattern in V5 and V6 or deep Q waves in left precordial leads “Adult” precordial R wave progression in the neonate
    • CONDUCTION ABNORMALITIES Bundle branch blocks are diagnosed as they would be in adults; RBBB occurs most commonly after repair of congenital heard defects and LBBB is very rare First degree AV block and Mobitz type 1 (Wenckebach) can be a normal variant in 10% of kids Complete AV block is usually congenital or secondary to surgery
    • Sinus Bradycardia Deviation from NSR - Rate < 60 bpm  Etiology: SA node is depolarizing slower than normal, impulse is conducted normally (i.e. normal PR and QRS interval).
    • Sinus Tachycardia Deviation from NSR - Rate > 100 bpm Etiology: SA node is depolarizing faster than normal, impulse is conducted normally. Remember: sinus tachycardia is a response to physical or psychological stress, not a primary arrhythmia.
    • Interpretation? Sinus Tachycardia
    • 1st Degree AV Block Etiology: Prolonged conduction delay in the AV node or Bundle of His.
    • Diagnosis? p 1st Degree AV Block
    • FIRST DEGREE HEART BLOCK PR interval > 5 small divisions, 0.2 secs Causes: myocarditis, acute rheumatic fever, drugs,
    • 50 bpm• Rate? • Regularity? regularly irregular nl, but 4th no QRS 0.08 s • P waves? • PR interval? lengthens • QRS duration? Interpretation? 2nd Degree AV Block, Type I
    • 2nd Degree AV Block, Type I Deviation from NSR  PR interval progressively lengthens, then the impulse is completely blocked (P wave not followed by QRS).
    • 40 bpm• Rate? • Regularity? regular nl, 2 of 3 no QRS 0.08 s • P waves? • PR interval? 0.14 s • QRS duration? Interpretation? 2nd Degree AV Block, Type II
    • 2nd Degree AV Block, Type II Deviation from NSR  Occasional P waves are completely blocked (P wave not followed by QRS).  Etiology: Conduction is all or nothing (no prolongation of PR interval); typically block occurs in the Bundle of His. MOBITZ TYPE 2
    • Rhythm #13 40 bpm• Rate? • Regularity? regular no relation to QRS wide (> 0.12 s) • P waves? • PR interval? none • QRS duration? Interpretation? 3rd Degree AV Block
    • Diagnosis? 3rd Degree AV Block
    • Diagnosis? RBBB
    • RIGHT BUNDLE BRANCH BLOCK Wide QRS > 0.12 s ( 3 small divisions) M morphology in V1 V1 “Rabbit Ears”
    • Diagnosis? LBBB
    • LEFT BUNDLE BRANCH BLOCK Wide QRS > 0.12 s ( > 3 small divisions) M morphology in V 6 and W in V1
    • ARRHYTHMIAS
    • 13 y/o with palpitations Paroxysmal supraventricular tachycardia (PSVT)
    • 22 day old with poor feeding Paroxysmal supraventricular tachycardia (PSVT)
    • Diagnosis? Paroxysmal supraventricular tachycardia (PSVT)
    • Paroxysmal supraventricular tachycardia (PSVT) Regularity: Regular Rate : >180/min P wave morphology: Different from sinus P wave or lost in preceeding T wave PR interval: 0.12 – 0.20 secs ( normal) QRS interval: normal (<0.08 s) Pattern: Sudden onset and offset
    • Diagnosis What is the rate? Is the QRS wide or narrow? Causes Ventricular tachycardia
    • Ventricular tachycardia Rate > 120 / min QRS > 0.08 secs Causes: myocarditis, LCAPA, tumour, Long QT, drugs, surgery
    • Diagnosis? Torsades de pointis
    • Torsades de pointis
    • Torsades de pointis Gradual change in amplitude of QRS Rate 150-250/min Prolonged QT interval, Hypokalemia, hypomagnesemia, drugs
    • Diagnosis?
    • Ventricular fibrillation Chaotic rhythm with wide QRS Causes: terminal rhythm in cardiac arrest
    • 70 bpm• Rate? • Regularity? regular flutter waves 0.06 s • P waves? • PR interval? none • QRS duration? Interpretation? Atrial Flutter
    • Atrial Flutter Deviation from NSR  No P waves. Instead flutter waves (note “sawtooth” pattern) are formed at a rate of 250 - 350 bpm.  Only some impulses conduct through the AV node (usually every other impulse).
    • QUESTIONS
    • 1. 2 year old with syncope and VT LONG QT SYNDROME
    • Intervals PR and QRS durations are relatively short from birth to age 1 and gradually lengthen during childhood; corrected QT (QTc) should be calculated on all pediatric ECGs During the first 6 mo of life, the QTc is slightly longer and is considered normal below 0.49 sec After that, any QTc above 0.44 sec is abnormal Other features of long QT syndrome include notched T waves, abnormal U waves, relative bradycardia and T wave alternans
    • LONG QT SYNDROME
    • LONG QT – SYNDROME. N-QTc- Infants 0.44 & NB-0.49sec 1. Beta-Blockers .Avoid drugs known to prolong QT-interval , electrolyte imbalance. 2. SOS pacemaker . W/F Syndromes associated with Long QT-interval. 3. Avoid competitive sports and swimming, teach CPR to the caretakers. Inform about SIDS.
    • 14-year old girl •Asymptomatic now •Intermittent palpitations, no syncope •SO2: 94% •Split S2, multiple heart sounds, no murmurs CASE 2
    • EBSTEIN ANOMALY Sinus, Tall P, splintered QRS
    • CASE 3 DILATED CARDIOMYOPATHY
    • There is marked LVH (S wave in V2 > 35 mm) with dominant S waves in V1-4. Right axis deviation suggests associated right ventricular hypertrophy (i.e. biventricular enlargement). There is evidence of left atrial enlargement (deep, wide terminal portion of the P wave in V1). There are peaked P waves in lead II suggestive of right atrial hypertrophy (not quite 2.5mm in height).
    • 4. INTRPREAT ECG H Y P E R K A L E M I A
    • • Changes appear when K+ falls below about 2.7 mmol/l • Increased amplitude and width of the P wave • Prolongation of the PR interval • T wave flattening and inversion • ST depression • Prominent U waves (best seen in the precordial leads) • Apparent long QT interval due to fusion of the T and U waves HYPOKALEMIA- ECG 5.
    • WPW SYNDROME6.
    • 69 Delta wave
    • •WPW- 3 features •Short PR interval , •Delta wave on upstroke of QRS •Slightly wide QRS
    • Station 1.a 1 day old neonate with respiratory distress ECG done What are ECG features? What is diagnosis? What disorders are associated? What precaution to be taken in emergency with such patients 7)
    • Inverted p/t wave, -ve qrs in lead 1.lead 2 n 3 reversed.lead 2 resemble 3 and 3 resemble 2 DEXTROCARDIA number of bowel, esophageal, bronchial and cardiovascular disorders (such as double outlet right ventricle, endocardial cushion defect and pulmonary stenosis) Kartagener syndrome Place rt Up N lt Lo lead on Up lft N Lo rt
    • ATRIAL FIBRILLATION8. Atrial activity is chaotic
    • Station No;9 A 10 day old newborn was rushed to NICU by a local doctor as he found different pattern of his cardiac activity. O/E child had fine rashes over the face specially the periorbital area . ECG done in ER showed (1x5=5) a) What is the ECG diagnosis? b )What is probable diagnosis? c) What is the pathogenesis of this disease? d) What is the Rx of this acute stage? e) What is the earliest age at which this cardiac defect can detected antenatally?
    • A)COMPLETE HEART BLOCK b) Neonatal Lupus c) Transfer of anti Ro antibodies between 12-16 wks of gestation d) Cardiac pacing e) 16 wks of GA
    • 10 2 months old baby admitted with recurrent cough cold, irritability, dyspnea and sweating. EKG done What is the diagnosis? (1/2) Name 4 EKG findings that helped u in diagnosis (1) What is the diagnostic test?(1/2) Name treatment options of it.(1)
    • Answer ALCAPA Inverted T wave, V5-V6 deep Q wave,ST elevation , inverted T wave Cardiac catherization Medical t/ t for CCF, ishamia and Surgical excision and ligation
    • ALCAPA_ECG # Description : ECG. Left axis deviation with left ventricular hypertrophy. Signs of anterolateral myocardial infarction: deep Q waves with T waves inversions in leads I, avL and deep Q waves with ST elevation in the left precordial leads.
    • A 12 yr old male child with c/o jt pain and fever admitted in ER.ECG done showed. What does this EKG strip shows (1) Name 3 EKG findings that helped you in diagnosis (1) What are the 2 clinical findings which will indicates severity?(1) Name treatment options of it.(1) What are other differential diagnosis?(1) 11
    • Answer RHEUMATIC PERICARDITIS Low voltage QRS, elevation of ST, Twave inversion Friction Rub and Pulsus Paradoxus steroid Viral Pericarditis, Benign Pericarditits, JRA
    • PERICARDITIS Diffuse upsloping ST segment elevations seen best here in leads II, III, aVF, and V2 to V6 12
    • MYOCARDITIS Sinus tachycardia with non-specific ST segment changes 13
    • 14
    • Name the wave marked by the asterisk In which condition will you find it? Which serious arrhythmia can it lead to? How will you treat it?
    • J WAVE,OSBORNE WAVE Hypothermia Ventricular arrhythmia Rewarm the patient
    • ECG showing R wave in lead V1 with RS in V2 (sudden transition), Right axis deviation , no q waves in lateral leads suggesting decreased pulmonary blood flow TETROLOGY OF FALLOT (TOF)15
    • PERICARDIAL EFFUSION Sinus tachycardia with low QRS voltage and QRS alternans 16
    • ASD There is right axis deviation with tall R waves V1-3 and corresponding deep S waves in V4-6. T waves are flat in V1 and inappropriately upright in V2-3. There is the RsR' pattern in V1 of partial rightbundle branch block. 17
    • VSD The Katz-Wachtel sign is tall diphasic RS complexes at least 50 mm in height in lead V2, V3 or V4 – mid precordial leads 18
    • PREMATURE BEATS Premature Ventricular Contraction Premature Atrial Contraction
    • Normal Variants Sinus arrythmia  Can be quite marked  Slows on expiration and speeds up on inspiration Extrasystoles  Can be atrial or venticular and are usually benign in the context of a structurally normal heart; typically monomorphic and associated with slower heart rates  Abolish with excercise
    • The Pediatric ECG…
    • In Summary Consider the age of the child, and the cardiac forces that may be dominant Use a structured approach and assess morphology, axis, and intervals in the context of age related normals Evaluate for the presence of structural disease Remember the “normal variants”