Pediatric EKGs

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Pediatric EKGs

  1. 1. INTERPRETINGPEDIATRICEKG’S 12 SEPTEMBER 2012 JOSEPH MAY, MD, MPH
  2. 2. REMEMBER THEBASICS1. Rate2. Rhythm3. P wave, PR interval4. QRS axis, QRS interval5. T wave, ST segment, QTc
  3. 3. CASE #1 14 year old 42 kg girl presents to ED with dizziness
  4. 4. Divide 300 by “large” box count: 300, 150,RATE 100, 75, 60, 50…
  5. 5. CASE #2 11 year old male while asleep
  6. 6. SINUS RHYTHM• P wave before every QRS• QRS after every P• All P waves look the same• Normal P wave axis (0 to 90 ) with upright P in leads I and aVF
  7. 7. DIAGNOSIS:SINUS RHYTHM? Respiratory sinus arrhythmia 2
  8. 8. SINUS ARRHYTHMIA• NORMAL variant in HR with respiration• Increases with inspiration and decreases with expiration• Variation can be up to 100%• More pronounced in younger patients
  9. 9. HEART BLOCK
  10. 10. HEART BLOCK
  11. 11. ATRIAL ARRHYTHMIAS
  12. 12. VENTRICULAR ARRHYTHMIAS
  13. 13. DIAGNOSIS: WOLFF-PARKINSON-WHITE WITH INTERMITTENT PRE-EXCITATION 4CASE #3 14 year old girl presents to ED with pounding in her chest
  14. 14. PR INTERVAL• Time required for atrial depolarization and conduction through the AV node• Varies with age and heart rate (increases with age and slow heart rate)• Shortened: WPW, normal variant, glycogen storage disease• Lengthened: 1st Degree Heart Block
  15. 15. WPW
  16. 16. WPW + SVT
  17. 17. AFIB in WPWWPW + A FIB
  18. 18. P WAVE MORPHOLOGYATRIAL ENLARGEMENT RIGHT ATRIAL ENLARGEMENT • Tall P waves > 3mm (3 boxes)Right atrial enlargement = tall P waves (> 3 boxes) • most often in lead II or V1, but can be seen in any• Usually in lead II or V1 lead
  19. 19. LEFT ATRIAL ENLARGATRIAL wave duration > 0.08 sec (2 boxes w • P ENLARGEMENT <12 moLeft atrial enlargement = wide P waves • P wave duration > 0.10 sec (2.5• P wave duration > 0.08 sec (2 boxes wide) in infant boxes < 12 months mo >12• > 0.10 sec (2.5 boxes wide) in child > 12 months • most often in lead II or V1, but can be s lead • P wave often notched or diphasic
  20. 20. 3 Northwest axis (left axis deviation)CASE #4DIAGNOSIS: 2-hr old male born to a G4P4 51 yo
  21. 21. ay be affected by ventricular hypertrophy, bundle branch block, AXIS or other conduction disturbances AXIS • Determined using the limb leads AXIS aVR The aVL opposite side Axis is of each leadeterminedusing the also has an Imb leads axis angle. This aVF portion III II is designated the negative pole of the lead. 7
  22. 22. AXIS AXIS LEAD I LEAD aVF O to +90 0 to -90 +90 to ±180 -90 to ±180
  23. 23. AXIS AXIS AXIS Compare the axis to normal values for the patient’s age
  24. 24. QRS FORCES FORCES QRS Right ventricular forces Left ventricular forces R waves in V4R, V1, V2 R waves in V5, V6 S waves in V5, V6 S waves in V4R, V1, V2 LV FORCE RV FORCE
  25. 25. DEXTROCARDIA DEXTROCARDIA If the heart is positioned in the right side of the chest, voltages in V3R and V4R will be larger than voltages in V3 and V4
  26. 26. DEXTROCARDIA DEXTROCARDIA
  27. 27. HYPERTROPHYRVH• Large R in V1 for age• Upright T in V1 after 3 days of age (normally may become upright again as early as 6 years old)• Q wave in V1, V3R, or V4R• Pure R wave in V1 in child older than 6 monthsLVH• Large R in V6 for age
  28. 28. LEFT VENTRICULAR HYPERTROPHY DIAGNOSIS: 8 ECG DONE AT HALF STANDARDNORMAL?
  29. 29. RIGHT BUNDLE BRANCH BLOCK Usually rSR’ in V1, V2 Slurred S in V5, V6BBB LEFT BUNDLE BRANCH BLOCK Wide S in V1, V2 Usually rSR’ in V5, V6 LEFT BUNDLE BRANCH BLOCK
  30. 30. CASE #5 16 year old male in ED following CPR
  31. 31. REPOLARIZATIONT wave in V1• Upright at birth• Inverts after 1-3 days of life• Stays inverted until preteen• Flips back upright as teen/adult
  32. 32. LQTS
  33. 33. BRUGADA

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