Introduction to Paedaitric ECG

Braja Ray MD, MRCPCH, FRCPCH, CCT Consultant Neonatologist and Paediatrician Ex Consultant NHS England Asst Prof RKM Seva Pratisthan

Electrophysiology

Location of leads

Tracing

Small box = 1 x 1 mm Large box = 5 x 5 mm Amplitude = 10mm/1mv Paper speed (horizontal boxes) Standard = 25 mm/sec

Approach

Rhythm Rate Axis Intervals Atrial enlargement Ventricular hypertrophy ST/T wave evaluation

Analyse this ECG

Rhythm, Rate, Axis, Intervals

Rythms

Sinus rhythm Tachyarrhythmia Narrow complex 2 small square Wide complex - >2 small square Bradyarrhythmia Atrioventricular block

Rate

60 / RR interval (in seconds) 300 / number of big boxes between consecutive QRS complexes 1500 / number of little boxes between consecutive QRS complexes

Calculate the rates

Sinus Rythm

P wave before every QRS QRS following every P wave Normal P wave axis Normal PR interval

Torsa de

Axis determination
Amplitude vector Add net R-S in lead I, R-S in aVF Plot in mm on grid (lead I horizontal, lead aVF vertical) Draw vector from origin to net amplitude Angle of vector = axis

Lt axis deviation
Normal variant AV septal defect (including primum ASD) Perimembranous inlet VSD Tricuspid atresia Single ventricle Double outlet right ventricle Noonan syndrome Left anterior hemiblock after MI

Long PR
First degree AV block Drugs Atrial surgery (scar tissue) Acute rheumatic fever (minor Jones criteria) Kawasaki disease

Short PR
Wolff-Parkinson-White Glycogen storage disease type IIa (Pompes) Fabry disease GM1 gangliosidosis Friedrichs ataxia Duchennes muscular dystrophy

Long QRS
Beginning of Q wave to end of S wave Use a lead where a Q wave is visible Normal = 0.04 - 0.08 (may be up to 0.09 in adolescents) > 0.12 = bundle branch block 0.10-0.12: evaluate morphology

RsR

Seen in right precordial leads: V1, rV3 Common: occurs in 7% of kids R and R both small and of short duration S wave larger than R and R R is less than 10 mm (15 mm in infants) Abnormal RSR may reflect RBBB or RVH (volume overload type)

Long QT
Onset of ventricular depolarization (Q wave) to end of ventricular repolarization (T wave) Do NOT include U waves Varies inversely with heart rate Best leads: II, V5, V6 QTC (Bazetts formula) = QT/square root RR Normal < 0.44 sec May be as high as 0.45 sec in adol/adult females May be as high as 0.49 sec in newborns (to 6 mo.) QT ruler

 Short QT Digoxin Hypercalcemia Long QT - Congenital Jervell-Lange-Nielsen AR, deafness Romano-Ward AD, normal hearing

Long QT - Acquired Metabolic Hypocalcemia Hypomagnesemia Malnutrition (anorexia) Drugs Ia and III antiarrhythmics Phenothiazines TCA CNS trauma Myocardial Ischemia Myocarditis

Atrial enlargement
Right atrial enlargement P wave amplitude > 2.5 mm in II Deep negative deflection in first 0.04 seconds in chest leads Left atrial enlargement Terminal portion of P wave Negative deflection in V1 beyond 0.04 sec Duration of negative deflection > 0.04 sec Total duration > 0.10 sec

RVH
Mild R > 15 mm (< 1 year) or > 10 mm (> 1 year) Abnormal RSR of normal to slightly prolonged duration in right chest leads Moderate Definite right axis deviation (non-RBBB) rR or pure R in right chest leads Significant S in left chest leads

RVH
Severe Marked RAD qR pattern V3R or V1 Tall pure R wave > 15 mm (any age) in right chest Upright T wave > 3-5 days of age Very tall R wave with ST depression and T wave inversion in V1 (strain) Deep S wave V6

LVH
LAD for age (more useful in neonates/infants) R in V5/V6 or I, II, III, aVF, aVL above normal S in V1/V2 above normal Abnormal R/S ratio (R/S in V1/V2 below normal) Deep/wide q wave in V5/V6 above fmm Tall symmetric T waves = LV diastolic overload With LVH, inverted T waves in I/aVF = strain

RBBB
Prolongation in terminal phase of QRS (terminal slurring Delayed conduction through RBB prolongs depolarization of RV Slurring is to the right and anterior RAD QRS above ULN for age Wide/slurred S in I, V5, V6 Terminal slurred R in aVR and V1, V2, V3r ST segment shift, T wave inversion (in adults)

RBBB: Etiologies ASD/PAPVR Right ventriculotomy Ebsteins Coarctation (< 6 months) LBBB Rare in children Seen in adults with ischemic and hypertensive heart disease