Approach to Pediatric ECG

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Approach to Pediatric ECG

• September 22, 2005
• Sultana Qureshi

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Indications

• Definitely
• Syncope
• Exertional symptoms
• Tachycardia/Bradycardia
• Palpitations

• ECG not as useful in isolated chest pain in kids
• Other indications

• Hypothermia
• Electrolyte disturbance
• Kawasaki Disease
• Rheumatic Fever

• Myocarditis/Pericarditis
• Congenital Heart Disease
• Myocardial Contusion
• Post cardiac surgery

• Seizure
• Drug ingestion
• Heart failure
• Cyanotic Episodes

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Pediatric ECG findings that may be normal

• Heart Rate gt100 bpm
• Sinus Arrythmia
• QRS Axis gt90
• Shorter intervals (PR, QT, duration of QRS, etc)
• T-wave inversion of right precordial leads
• Dominant Right precordial R-waves
• Q-waves (inferior and lateral leads)
• ST elevation due to early repolarization

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Development of the Heart (Relative to ECG
findings)

• At Birth
• Thickness of RV gt LV
• ECG RAD (60-160)
• RV dominance in precordial leads
• T-wave upright in V1-V3

Pulmonary vascular resistance Systemic Vascular
Resistance

• 6 months
• Adult proportions of ventricles
• ECG LV dominance
• T-wave inverted in V1-V3

• 1 year
• QRS Axis 10 - 100

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Step 1 Identify
Approach to Pediatric ECG
AGE!
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Step 2 Heart Rate
Approach to Pediatric ECG
TABLE 164-2 -- Age-Specific Rates TABLE 164-2 -- Age-Specific Rates TABLE 164-2 -- Age-Specific Rates
Age Beats per minute Beats per minute  
Age Range (degrees) Mean  
First week 100175 130  
1 week to 3 months 85190 160  
312 months 110180 140  
13 years 98163 126  
35 years 65132 98  
58 years 70115 96  
816 years 55107 79  
Rosen (2005)
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Step 2 Heart Rate
Approach to Pediatric ECG
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Step 2 Heart Rate
Approach to Pediatric ECG

• Sinus Arrythmia
• more common and profound in children
• clinical correlation

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Step 3 Rhythm
Approach to Pediatric ECG

• Same analysis as adults
• Age specific Intervals
• For the pediatric cardiologists!
• Also measure P-axis in rhythm analysis for
  source of ectopic foci

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Step 3 Rhythm
Approach to Pediatric ECG
Age HR bpm QRS axis degrees PR interval seconds QRS interval seconds R in V1 mm S in V1 mm R in V6 mm S In V6 mm
1st week 90-160 60-180 0.08-0.15 0.03-0.08 5-26 0-23 0-12 0-10
1-3wks 100-180 45-160 0.08-0.15 0.03-0.08 3-21 0-16 2-16 0-10
1-2 mo 120-180 30-135 0.08-0.15 0.03-0.08 3-18 0-15 5-21 0-10
3-5 mo 105-185 0-135 0.08-0.15 0.03-0.08 3-20 0-15 6-22 0-10
6-11 mo 110-170 0-135 0.07-0.16 0.03-0.08 2-20 0.5-20 6-23 0-7
1-2 yr 90-165 0-110 0.08-0.16 0.03-0.08 2-18 0.5-21 6-23 0-7
3-4 yr 70-140 0-110 0.09-0.17 0.04-0.08 1-18 0.5-21 4-24 0-5
5-7 yr 65-140 0-110 0.09-0.17 0.04-0.08 0.5-14 0.5-24 4-26 0-4
8-11 yr 60-130 -15-110 0.09-0.17 0.04-0.09 0-14 0.5-25 4-25 0-4
12-15 yr 65-130 -15-110 0.09-0.18 0.04-0.09 0-14 0.5-21 4-25 0-4
gt 16 yr 50-120 -15-110 0.12-0.20 0.05-0.10 0-14 0.5-23 4-21 0-4
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Step 4 QRS Axis
Approach to Pediatric ECG
3 days old
12 years old
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Step 4 QRS Axis
Approach to Pediatric ECG
TABLE 164-5 -- Age-Specific QRS Axis (Frontal Plane) TABLE 164-5 -- Age-Specific QRS Axis (Frontal Plane) TABLE 164-5 -- Age-Specific QRS Axis (Frontal Plane)
Age Range (degrees) Mean (degree)
17 days 80160 125
14 weeks 30180 110
13 months 10125 70
36 months 2080 65
612 months 0100 65
13 years 20100 55
38 years 20120 60
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Step 5 Specific Waveforms
Approach to Pediatric ECG

• Large right precordial R-waves (RV dominance)
• T-wave inversion of V1- V3, V4R
• Juvenile T wave variant (normal from 7d- 7y)
• Abnormal if T-waves upright between 7d -7y, and
  indicator of RVH (even if do not meet voltage
  criteria for RVH)
• Q-waves (inferior and lateral leads)
• ST elevation from Early Repolarization, and
  J-point depression

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Step 5 Specific Waveforms
Approach to Pediatric ECG
3 days old
12 years old
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Normal Adult ECG
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Step 5 Specific Waveforms
Approach to Pediatric ECG
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Young Adult
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2 weeks old
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Pediatric ECG findings that may be normal

• Heart Rate gt100 bpm
• Sinus Arrythmia
• QRS Axis gt90
• Shorter intervals (PR, QT, duration of QRS, etc)
• T-wave inversion of right precordial leads
• Dominant Right precordial R-waves
• Q-waves (inferior and lateral leads)
• ST elevation due to early repolarization