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Pediatric-EKG-Interpretation-2018.ppt
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- 2. Introduction Values are dynamicand change with age.
- 3. Introduction 12 lead EKG Anatomyof an impulse
- 4. 12 Lead ECG EKGis a voltmeter ie measures voltage which has magnitude and direction. Voltage displayed on the Y axis ( 1mV=10mm) and time is displayed on the x axis ( 1 little block = 0.04 seconds)
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- 8. Anatomy of anImpulse
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- 11. ECG Analysis Always readan EKG systematically 1. Rhythm 2. Rate 3. QRS axis 4. Intervals : • PR interval • QRS duration • QT interval 5. QRS amplitude, R/S ratio, abnormal Q waves 6. ST-segment and T wave abnormality
- 12. 1. Rhythm Sinus ornot Sinus rhythm: P before every QRS P wave morphology Regular PR interval Normal P wave Axis
- 13. 1. Rhythm P waveduration < 0.07 sec in infants, < 0.09 in children LAH duration > 0.08 sec in infants and >0.1 sec in children P wave amplitude < 3 mm RAH > 3 mm Combined atrial hypertrophy
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- 16. 2. Rate 1 mm= 0.04 sec, 5 mm = 0.2 sec Measure between R – R’ measure duration in seconds, Rate = 60/duration measure large divisions, Rate = 300/ number of large divisions 1 minute = 60 seconds, and 300 large divisions
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- 19. 2. Rate Count R-Rcycles In 6 large divisions, multiply cycles by 50 In 3 seconds = marks on top margin of paper , multiply cycles by 20 Quick and easy; 300/150/100/75/60/50 Tachycardia and Bradycardia, check normal values for age.
- 20. 3. QRS Axis HexaxialSystem, Limb leads Frontal Plane Left vs right, superior and inferior Lead I left (positive) vs right (negative) AvF downward (positive) vs upward (negative)
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- 22. Horizontal Reference System Rightand left precordial leads V2 is perpendicular to V6 V2 anterior (positive) posterior (negative) V6 left (positive) right (negative) V1 anterior and right (positive) posterior and left (negative)
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- 25. 3. QRS Axis RAD,LAD look at normal ranges for age Superior Axis DDX: Endocardial cushion defect Tricuspid atresia RBBB Overlap with LAD may occur with Left anterior hemiblock
- 26. 4. Intervals PR IntervalQRS Duration and QTC Interval
- 27. PR Interval PR interval Varieswith age and rate Increases with age and decreases with rate
- 28. 4. Intervals Increased PRinterval, DDx First degree AV block Myocarditis, rheumatic or viral Digitalis toxicity ECD, ASD, Ebsteins’s anomaly
- 29. 4. Intervals Decreased PRinterval, DDx: Preexcitation WPW
- 30. 4. Intervals QRS duration Increaseswith age Ventricular conduction Disturbances Ventricular rhythms
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- 32. QRS Duration Initial slurring:Preexcitation, WPW Ventricular Conduction Disturbances Terminal slurring: RBBB, LBBB Diffuse slurring: Intraventricular block Hyperkalemia, procainamide, quinidine, myocardial fibrosis, myocardial dysfunction of metabolic or ischemic nature
- 33. Preexcitation WPW Short PR interval( check tables) Delta waves, initial slurring of QRS Wide QRS duration May mimic VH or RBBB
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- 35. Ventricular Conduction Disturbances Initial Slurring Preexcitation DiffuseSlurring Intraventricular block Terminal Slurring Vent rhythm, RBBB, LBBB
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- 37. RBBB Terminal Slurring isright and anterior RAD for terminal portion Prolonged QRS duration Wide slurred S in I, V5 V6 Terminal slurred R’ in aVR, V4R, V1, V2 T waves inversion common in adults, but not in children
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- 41. QRS duration Ventricular Rhythms: PrematureVentricular Conctractions Ventricular Tachycardia Implanted Ventricular Pacemaker
- 42. QTc interval QTc =QT/√ R-R interval <0.44 <0.49 in infants
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- 44. QTc Interval Increased QTcDDX; Cardiac Causes: Myocarditis, diffuse myocardial disease (hypertrophic and dilated cardiomyopathy) Long QT syndrome (Jervell and Lange – Nielsen , Romano-Ward syndrome
- 45. Prolonged QTc Interval Nonecardiac causes: Hypocalcemia, head trauma, malnutrition Drugs; Antibiotics (Amp, Em,TMP-Sulfa) Anti psychotic (phenothiazines) Anti depressants ( tricyclic) Anti histamines (Seldane) Anti arrhythmic drugs Arsenics Organophosphates
- 46. Hypertrophy QRS voltage: Increases inthe direction of the respective ventricle. Normal QRS duration LVH increased R voltages in Leads I, II, aVL, sometimes aVF and III, tall R’s in V5- 7 with deep S’s in V1-2 and V3R and V4R
- 47. Hypertrophy RVH increased Rin aVR and III, and deep S in lead I, increased R in V1-2, V3R and V4R and deep S ‘s in V5-6
- 48. Hypertrophy Changes in TAxis Abnormal T axis with increased QRS-T angle = strain Upright T waves in RPL after day 3 of life and up to adolescence = strain Inverted T waves in LPL = strain
- 49. Hypertrophy Q waves Abnormal Qwaves are either deep or wide or both. Q waves are normally present in LPL and absent in RPL Deep and wide Q’s are present in myocardial infarction Deep Q’s are present in volume overload VH Presence of Q’s in RPL (RVH or V inversion) Absence in LPL ( LBBB or V inversion)
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- 54. CVH Presence of RVHand LVH criteria Positive criteria for RVH or LVH and large voltages for the other Large equiphasic QRS complexes in 2 or more limb leads and the mid precordial leads
- 55. ST Segments Up to1mm elevation or depression is acceptable in children Examples of nonpathologic ST segment shift: Early repolarization, J point depression
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- 57. St Segment Pathologic depression; Downwardslant with a diphasic or inverted T wave Horizontal elevation or depression sustained for over 0.08 seconds ST depression; hypertrophy, strain, ischemia, digoxin effect ST elevation; pericarditis, injury
- 58. T waves < ½of QRS Positive in I, II, aVL, V4-6 Negative in aVR, V3R, V1-2 Abnormal inverted T waves: ischemia, hypertrophy and hyperventilation Flattened T waves: hypokalemia Peaked T waves : hyperkalemia, ventricular hypertrophy or BBB
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- 60. P wave Atrial Contraction Indicationof atrial morphology Does the p wave have a normal axis? (P waves are positive in I,II and aVF) Rt atrial enlargement: Peak P wave >2.5mm in II, V1,V2 Lt atrial enlargement: P wave broad/bifid (P wave 0.04 to 0.08 in infancy. 0.06 to 0.1sec in older children)
- 61. RVH Monophasic or pureR wave in V1 V4R Upright T wave in V1 after 7 days until 7 years R/S ration in V1 : 0-3/12:6.5, 3-6/12:4,6/12 to 3years: 2.4 3-5 years:1.6 R in V1 >20mm at all ages S wave in V6 >15mm in first week, 10mm up to 6 months, 7mm from 6 to 12 months, 5mm above 1 year T wave inversion extending to V4 Widening of QRS complex>0.08
- 62. LVH Tall R wavesin V5/V6( >40mm over 1year, >30mm under 1 year) Deep S wave in V1 Q wave ≥4mm in V5/V6 Widening of QRS duration/Flattening of T waves in V5, V6 T wave inversion in V5, V6 (Severe) ST segment depression (Severe)
- 63. Electrical Heart Diseases Tachyarrhythmia 0-5years Serious Non- Specific Symptoms Maternal History 5- 10 years Significant Specific Symptoms Maternal and Patient History 10-16 years Significant and Interesting Specific Symptoms Patient History History is the
- 64. Supraventricular tachycardia SVT Infants andToddlers Unaware Funny Turn Pallor, Poor feeding Signs of CCF Older children Aware Palpitation Dizziness
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- 66. Arrhythmias WPW Syndrome AVRT AF ChildrenAdults Less Mortality Lethal AF VF More common Incidence: 11-38% Regular Irregular Narrow/Wide Bizzare wide complex
- 67. Supraventricular tachycardia Commonest tachyarrhythmiain childhood Majority has a structurally normal heart Short lived SVTs are not life threatening Baseline ECG: May reveal predisposing features 24 hour ECG Event recorder
- 68. SVT in children CommonArrhythmia in children Can be asymptomatic Adenosine mainstay for acute attacks Chronic SVTs can lead to poor LV function
- 69. SVT Long term treatment Notreatment Vagal manoeuvres Drugs Beta Blockade: Propranolol, Atenolol Flecanide, Amiodarone Radiofrequency Catheter Ablation