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Pediatric EKGs
- 1. INTERPRETING PEDIATRIC EKG’S 12 SEPTEMBER 2012 JOSEPH MAY, MD, MPH
- 2. REMEMBER THE BASICS 1. Rate 2. Rhythm 3. P wave, PR interval 4. QRS axis, QRS interval 5. T wave, ST segment, QTc
- 3. CASE #1 14 year old 42 kg girl presents to ED with dizziness
- 4. Divide 300 by “large” box count: 300, 150, RATE 100, 75, 60, 50…
- 5. CASE #2 11 year old male while asleep
- 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. DIAGNOSIS: SINUS RHYTHM? Respiratory sinus arrhythmia 2
- 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. HEART BLOCK
- 10. HEART BLOCK
- 13. DIAGNOSIS: WOLFF-PARKINSON-WHITE WITH INTERMITTENT PRE-EXCITATION 4 CASE #3 14 year old girl presents to ED with pounding in her chest
- 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. WPW
- 16. WPW + SVT
- 17. AFIB in WPW WPW + A FIB
- 18. P WAVE MORPHOLOGY ATRIAL 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. LEFT ATRIAL ENLARG ATRIAL wave duration > 0.08 sec (2 boxes w • P ENLARGEMENT <12 mo Left 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. 3 Northwest axis (left axis deviation) CASE #4 DIAGNOSIS: 2-hr old male born to a G4P4 51 yo
- 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 lead etermined using the also has an I mb leads axis angle. This aVF portion III II is designated the negative pole of the lead. 7
- 22. AXIS AXIS LEAD I LEAD aVF O to +90 0 to -90 +90 to ±180 -90 to ±180
- 23. AXIS AXIS AXIS Compare the axis to normal values for the patient’s age
- 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. 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. DEXTROCARDIA DEXTROCARDIA
- 27. HYPERTROPHY RVH • 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 months LVH • Large R in V6 for age
- 28. LEFT VENTRICULAR HYPERTROPHY DIAGNOSIS: 8 ECG DONE AT HALF STANDARD NORMAL?
- 29. RIGHT BUNDLE BRANCH BLOCK Usually rSR’ in V1, V2 Slurred S in V5, V6 BBB LEFT BUNDLE BRANCH BLOCK Wide S in V1, V2 Usually rSR’ in V5, V6 LEFT BUNDLE BRANCH BLOCK
- 30. CASE #5 16 year old male in ED following CPR
- 31. REPOLARIZATION T wave in V1 • Upright at birth • Inverts after 1-3 days of life • Stays inverted until preteen • Flips back upright as teen/adult
- 33. LQTS
- 34. BRUGADA