1. Pediatric ECG:A practical Approach
Dr ANIL S.R
Consultant Pediatric Cardiologist
MIMS Calicut

2. •A wriggling neonate
•A crying infant
•An apprehensive child
•A ticklish adolescent
ECG in pediatric Practice

4. •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

5. Normal neonate

6. 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

7. Normal Child

8. Normal adolescent

9. 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

10. LV/RV Mass ratio
30w 1.2:1
33w 1:1
Birth 0.8:1
6m 2:1
Adult 2.5:1

11. 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

13. Leads
Bipolar leads : I , II, III
Unipolar leads : aVR, aVL, aVF
V1 to V6

14. 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)

15. 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

19. Right atrial Enlargement

20. Left atrial Enlargement

21. Right Ventricular Hypertrophy

22. Left Ventricular Hypertrophy

24. Common congenital heart defects
Left to right shunts
Stenotic lesions
Cyanotic heart diseases

25. Secundum ASD

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

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

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

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

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

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

35. PDA ... Note prominent LV forces

36. PDA in Rubella syndrome patients
Left axis deviation due to injury
to conduction tissues

38. AS with LVH, note strain pattern

39. AS with significant LVH and strain pattern

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

41. Coarctation
• In infancy, due to pulmonary
hypertension, Right axis and RVH are
common
• In older patients, LVH occurs

42. Coarctation in an older child

44. Valvar PS

46. Sick TOF

47. TOF - Transition occurs in V1
Importance of right chest leads

49. D-TGA in a older child

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

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

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

54. TAPVC

55. TAPVC ... ECG shows features of PAH

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

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

60. Single ventricle - RAD with LV forces

61. In a cyanotic child:
• Right ventricular forces: TOF
TOF with pulmonary atresia
TGA
TAPVC, Common atrium
• Left ventricular forces:Tricuspid atresia
Pulmonary atresia with IVS
Hypoplastic right heart
Single ventricle
Ebsteins
• Bi-ventricular forces: Truncus
DORV
• Normal ECG: Pulmonary AV fistula
Anomalous systemic venous return

62. Provides valuable clues in diagnosis
Invaluable in arrhythmia
Comprehensive assessment before surgery
Read and analyze ECGs
Conclusion