Pediatric ECG’s

Christine Kennedy

EM Rounds

May 20, 2010

Objectives

• Highlight normal findings on a Pediatric ECG– T waves– Q waves– ST segments

• Identify some key abnormal findings on a Pediatric ECG (case examples)

Normal Findings

T waves

2 week male with ?Apparent Life Threatening Event

Inverted T waves in V1

Take home point #1 T waves

• Newborn (week 1): – may be either inverted or upright in V1

• Between 8 days & 8 years– Should be inverted in V1 (if not = RVH)

Normal Findings

Q waves

1-year-old male, asymptomatic, Mom told that child has a murmur

Q waves in inferior/lat leads

Take home point #2Q waves

• Q waves are normal in II, III, aVF, V5 & V6– Absence of Q wave: suspect a VSD

• Amplitude of accepted Q wave varies with age– Use lead III as reference

• 6 months: up to 7 mm• 12 months: up to 5 mm• 8 years: up to 3 mm

8 year old boy referred for an irregular heart rhythm

•Sinus rhythm

•Varied heart rate

Take home point #3Sinus Arrhythmia

• Very common in children ages 2-10

• Normal variant– Associated with increased vagal tone

• Need to have normal P wave morphology and normal PR intervals*

11 year old male with chest pain

Sinus rhythm, rate 60

ST elevation I, II, V2-6

Take home point #4ST elevation

• Early Repolarization– Normal Variant, common in adolescents– ST elevation <25% of T wave height– Symmetric T waves

Now for some abnormal ECG’s

3-year-old girl referred with systolic murmur

rsR’ in V1

Take home point #5RSR’

• If R’>R in V1– Suspect RVH– 25% chance of having ASD

8 week male with tachypnea

Left axis deviation [30-135]

RVH: S in V6 >10 [0-10], Q wave in V1

LVH: R in V6 >21 [5-21], Q wave >4mm in V6

Left axis deviation

RVH: S in V6 >10 [0-10]

LVH: R in V6 >21 [5-21]AVSD

Take home point #6 Left Axis Deviation

• LAD in first couple of months: suspect AVSD

9 year old male with loud systolic murmur at LUSB

Axis +130

Pure R in V1

S in V6>4 mm

Axis +130

Pure R in V1

S in V6>4 mm

Pulmonary Stenosis

Take home point #7RVH

• RV dominance & RAD in first couple months of life is normal– Large amplitude R waves in V1, small

amplitude R waves in V5 & V6

• By 5-7 years– Expect more “adult norms” for R waves

• R in V1: 0-14• R in V6: 4-25 (4-21 by 16 years)

4-month-old infant with wheezing and cardiomegaly

ST elevation in V1-3, 5, V3R, V4R

Inverted T waves in V5-6

ALCAPAAnomalous Left Coronary Artery

from the Pulmonary Artery

Take home point #8ST elevation

• Children do get ischemia– If child is irritable with a history of recurrent

wheeze/cough and ST elevation is present, consider ALCAPA

Summary

1. T waves• Should be inverted in V1 between 8 days & 8

years (if not = RVH)

2. Q waves• Normal in II, III, aVF, V5 & V6• Absence of Q wave: suspect a VSD

3. Sinus Arrhythmia• Very common in children• Look for normal P wave morphology & PR

interval

Summary

4. Early Repolarization• Normal Variant, common in adolescents• ST elevation <25% of T wave height

5. RSR’• If R’>R in V1, suspect RVH

– 25% chance of having ASD

6. Left axis deviation• If present in first couple of months: suspect AVSD

Summary

7. RV dominance & RAD • Normal in first couple months of life

8. Children do get ischemia• If child is irritable with a history of recurrent

wheeze/cough and ST elevation is present, consider ALCAPA

Table of LVH/RVH criteria

Table of Normals

References

• Pediatric ECG Interpretation-An Illustrative Guide. B.J. Deal, C.L. Johnsrude, S.H. Buck.

• The Pediatric ECG. G.Q. Sharieff, S.O. Rao. Emerg Med Clin N Am 24 (2006). 195-208.

Other Pearls

• PR interval short at birth (0.08-0.15), increases with increasing muscle mass

• QRS shorter – Abnormal If >0.08 in children <8 years

• LVH– LV strain in V5&V6 (flipped T’s), mature precordial R

wave progression in newborn

• Sinus tachycardia– When febrile, expect HR to increase by 10 for every

degree elevation in temperature