Pediatric Ecg Flashcards
Heart rate from rhythm strip
Multiply with 6. One paper is 10 sec
Paper is 25 cm long. Paper speed is 25 mm/Sec. Hence..
1mm in ECG is……..SECONDS
0.04. SECONDS
Prolonged PR interval in Ped ecg
Ebsteins, ASD, ECD etc, Myocarditis,Hyperkalemia, Digitalis
Short PR interval in Ped ecg
Glycogen storage disease
R/S ratio <1 in V6 indicates RVH after ____age
One month
Highly specific for RVH in Pediatric ECG
qR in V1
Abnormal Q waves in V5 and V6 in Ped ecg indicate
LVH
Q also indicates Vol overload or MI
Q waves can be normally found in children in V5,6 but not in I aVL
Described in another place as a may be seen in I and aVL
Inverted T waves in I and aVL in Ped ecg indicate
LV strain pattern
ECG finding in biventricular hypertrophy in V2-5
Large equiphasic QRS . Also in 2 or more limb leads
Different implications of Deep Q waves versus Deep and wide Q Waves
Deep and wide-MI and fibrosis. If deep only more s/o Volume overload
ST segment is judged in relation to ——
TP segment
T wave finding in first week of life
Upright in all precordial leads
T wave change after first week of life
T inversion in V1-3
Tall peaked T waves indicates
Volume overload
Early depolarization
Hyperkalemia
Large deep inverted T and Neuro
Raised intracranial pressure
Hypothyroidism and T wave change
Flat T waves
U waves seen in
Hypokalemia
Sinus Brady
Most common type of SVT in children
AVRT:
NB:-AVnRT is rarely seen before 2yrs of age. As you age it becomes more common
Sinus arrhythmias defined as RR Interval variation more than
120 ms or 3 small spaces
In situs solitus P wave is always positive in
I,II,V4-6
Negative in aVR
Variable in others- Almost always upright in aVF
Normal P wave axis
30-60
More than 75 is abnormal
More than 90 indicates Situs inversus
Normally the widest P wave can be upto
100 ms
i.e. 2.5 small divisions
Max amplitude is also 2.5
Normal PR in a child
110-160 ms: Neonate it is less than 140 ms
Short PR is <100 ms
Adult-120-200ms
QRS duration is traditionally measured in
Limb leads or V1-2
> 100 ms may be abnormal
Low voltage QRS means
<5mm in limb leads and<10mm in precordial leads
High voltage limb leads
> 20mm in limb leads and >30 mm in precordial leads.
High voltage complexes may be normal
Small q is normally seen in pediatric ecg in
1,aVL,V4-6 and aVF
Normal q is <3 mm deep and <1mm wide
Q of more than 4 mm is considered abnormal
Usually Q is less than 25% of R height
Early transition of QRS
If it occurs in V2
Late transition of QRS
If it happens in V5
Normal QRS axis in children
Upto 1 year:: 90-150
1-8 years:: 45-105
Above 8:: less than 90
Zulfikar
Clockwise loop in pediatric ecg
Q in 2,3,aVF
Counter in 1,aVL
Anti’s are kept little laterally
RUQ axis and loop
RUQ Axis + clockwise loop=extreme RAD;
If counter clockwise loop= extreme LAD
ST elevation which may be normally seen in young
<1mm in V1-3
Maximum height of normal T
Upto 6 mm in limb leads
Upto 10 mm in precordial leads
T wave in pediatric popl- normal pattern
T UPRIGHT upto 3 days–V3R,V1,V2
From 4th day —T is INVERTED upto V3
Older children V3 T is usually upright
U wave amplitude
Usually 1/4 of T wave and is positive
Repolarisation of His Purkinje system
VT in children
Uncommon in children. Can occur in Long QT syndrome
How to diagnose Biventricular hypertrophy in children
- Katz Wachtel phenomenon- Tall R and deep S in mid precordial leads measuring >60 mm
- LVH + RAD or Clockwise loop
- RVH + LAD
- Independent RVH and LVH
How to diagnose LAE in Pediatric ECG
- > 120 ms
- In bifid P - interpeak distance > 40 ms
- V1 p > 1 mm depth and width(MORRIS criteria)
- P axis < -30
- MACRUZ index- P duration/ PR segment >1.6
RAE Diagnosis
P axis > 60; > 3mm p in Ld II;P initial force in V1 > 1.5mm
Modified Lyon Sokolow criteria in Pediatrics
R in V5/6 plus Sin V1. >45mm (Adult-35)
R inV5/6> 35mm( Adult-25-?)
R in aVL, aVF> 20 mm (Adult-11 in aVL)
LVH of volume overload criteria
- Prominent Q in I, aVL., V5-6
- Tall R in V5-6
- Upright symmetrical tall T in V5-6
LVH of pressure overload criteria
- No significant q in 1,aVL, V5-6
- Slurred upstroke of R in left precordial leads
- Lvh with strain pattern in V5-6—asymmetric T inversion with ST sagging
How to diagnose RVH in pediatric ECG
- Upright T in V3R,V1 after day 3
- R inaVR more than 5
- RAD > 110
- R in V1 > 7 mmin child above 6 yrs
- R in V1 + S in V6 > 11 mm
- qR in V3R or V 1
7.R/S more than. :::5 if less than 6 month
::3 if 6 months- 3 yrs
::1.5 3-6yrs
More than 1 after 6 yrs
Average heart rate in children peaks by
2nd month and then decreases
Max heart rate in neonate
230( starts at 120!)
Avg heart rate at5 yrs
100
Average resting heart rate at 1 year
120
Heart rate reaches adult values by
15 yrs
QRS axis becomes normal by —–age
1 yr
Common causes of left axis deviation at birth
TA and AV canal defect
Also causes counterclockwise loop with q in I aVL
In neonates PR intervals can be as short as
80 ms
Difference in preterm (28 wks) ECG from term
Chest leads may show LV dominance with normal or left ward QRS axis.
How to quickly spot an abnormal axis
If lead I or II is negative it is usually abnormal
Triclofos ( pedichloryl) dose in children
50 mg/kg
ie 1/2 ml/ kg wt
14 lead ECG is routine in child because
More proportion of heart is towards right side. So V3 R and V4 R
What happens to ECG voltage with inspiration and expiration
Inspiration voltage decreases
Expiration voltage increases
In children upper limit of PR interval is taken as
160 ms
For a newborn upperlimit is 120 ms(some say 140)
Adult-200 ms
Short PR interval in Pediatric is considered as less than
100 ms
Short PR interval in children
DMD,
Pompe’s disease
As a normal Variant etc
Long PR interval in children, rule out
Myocarditis-Viral, Rheumatic, Lymes disease
Drugs etc
Varying PR interval is seen in
Wandering Atrial Pacemaker
Mobitz 1
CHB
Where can you call an S wave rather than a QS
In a lead where q is not expected as in V1- we can call the wave as S wave and not qS
ST elevation in Pediatric ECG consider
Kawasaki, Anomalous coronaries
In adults inverted T wave may be seen upto
V3 (rare)
Tall T wave means-roughly
More than 2/3rd of preceding QRS wave
Small T -if less than 1/8 th of preceding QRS
Tall T can be a normal variation
T wave amplitude must be checked in
V5,6
Inverted T is normal in
aVR, Ld3
In adults T wave in V1 is
Upright
Physiological T inversion is possible in V5/6 in setting of
- Trained athletes
- Fever
- Anxiety
But first rule out pathological causes
T wave alternans is seen in
- Congenital
2. Acquired- Pentamidine toxicity
In situs inversus p axis is in
Rt lower quadrant
Isolated levocardia means
Both ventricles and atria are inverted but still heart remains in left side of chest
