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Pediatrics ECG

By Dr ali bel kheir

Pediatrics ECG By Dr ali bel kheir يصاعملا يكرت ىلإ يندشرأف يظفح ءوس عيكو ىلإ

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Electrocardiography

Electrocardiography Electricity of the heart  Atrial contractions  P wave  Ventricular contractions  QRS

Electricity of the heart

Electrocardiography Electricity of the heart  Atrial contractions  P wave  Ventricular contractions  QRS

Atrial contractions P wave

Ventricular contractions QRS complex

Ventricular repolarizations T wave

2 interval ( PR&QT)

2 segment (PQ&ST)

…………………………………………………………………………………………………………………………

Precordial leads:

V4R: 5th intercostal space, right midclavicular line V1: 4th intercostal space, right sternal border V2: 4th intercostal space, left sternal border V3: use this lead for V4R, must label as such on ECG. V4: fifth intercostal space, right midclavicular line V5: anterior axillary line, same horizontal plane as V4 V6: midaxillary line, same horizontal line as V4. Limb leads: Place on top part of arm or leg (less muscle interference). …………………………………………………………………………………………………………………………

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Common Findings on the Paediatric ECG

The following electrocardiographic features may be normal in children:

Heart rate >100 beats/min

Rightward QRS axis > +90°

T wave inversions in V1-3 (“juvenile T-wave pattern”)

Dominant R wave in V1

Marked sinus arrhythmia

Short PR interval (< 120ms) and QRS duration (<80ms)

Slightly peaked P waves (< 3mm in height is normal if ≤ 6 months)

Slightly long QTc (≤ 490ms in infants ≤ 6 months)

Q waves in the inferior and left precordial leads.

1. First thing’s first

Check the name on the top of the ECG is this your patient?

Check the date is this the one you ordered?

Check for the age of the patient the heart physiology and the

normal values differ in different age groups in the pediatric population …………………………………………………………………………………………………………………………

2. Technical Aspects

a)

b)

Is the ECG full standard?

Full standard means that the ECG was not reduced in size so that it can fit on the paper

Look at the left hand side of each line

If it is full standard, the rectangle’s height should be 2 big squares

If it is half standard, the rectangle’s height is only 1 big squareYou will need to double all the waves to normalize them

 You will need to double all the waves to normalize them What is the paper
 You will need to double all the waves to normalize them What is the paper

What is the paper speed?

The standard speed is 25mm/sec

That means :

each little box is 0.04 seconds

each big box is 0.2 seconds

5 large box=25 mm=1 seconds

each big box is 0.2 seconds 5 large box=25 mm=1 seconds 2 Visit us on
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3.

Rate

a) Normal, Fast or Regular Rates  Find 2 adjacent R waves, count the number
a)
Normal, Fast or Regular Rates
Find 2 adjacent R waves, count the number of big squares between the R’s
Divide 300 by the number of big squares  this is your rate
b)
Slow or Irregular Rates
The easiest way to calculate the rate is to count the total number of
QRS complex along the length of the entire strip and multiply it by 10 = this
is your rate (bpm)

Note: The normal value for heart rate ranges dramatically depending on your patient’s agecheck tablet at end …………………………………………………………………………………………………………………………

4. Rhythm

a) Analysis

Is the rhythm sinus? Sinus rhythm:

Is there a P wave before each QRS complex?

Is there a QRS complex after every P wave?

Are the P waves upright in leads I, II, III?

Do all P waves should look the same?

Are all P wave axis normal (0 to +90)?

Are the PR intervals constant?

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Is the rhythm regular or irregular? Do the P waves and QRS follow a regular pattern?

If it is irregular, is it consistently irregular or consistently irregular?

b) Abnormal Rhythms

Atrial Flutter

 

Rapid atrial rate (~300 bpm) with varying ventricular rate

Atrial Flutter    Rapid atrial rate (~300 bpm) with varying ventricular rate
 

Sawtooth pattern

Suggests significant pathology

Atrial

Very fast atrial rate (350-600 bpm)

Atrial  Very fast atrial rate (350-600 bpm)

Fibrillation

 
 

Irregularly irregular

No P waves, normal QRS

Suggests significant pathology

Ventricular

 

Wide, unusually shaped QRS

Ventricular    Wide, unusually shaped QRS

Tachycardia

T waves opposite direction of QRS

 

HR 120-200 bpm

Suggests significant pathology

Ventricular

 

Very irregular QRS

Ventricular    Very irregular QRS

Fibrillation

Rate is rapid and irregular

 

“terminal arrhythmia

Premature

 

Length of two cycles (R-R) usually shorter

Premature    Length of two cycles (R-R) usually shorter

Atrial

Contraction

 

Preceded by P wave, followed by normal QRS

(PAC)

No hemodynamic significance

Premature

 

Premature, wide QRS, no P waves, T wave opposite to

Premature    Premature, wide QRS, no P waves, T wave opposite to

Ventricular

Contraction

 

(PVC)

 
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5. Axis

Axis is the “conduction flow” of the heart

Normal axis varies with age i.e. newborns have a right axis deviation because the left and right ventricles are the same size due to fetal circulation

Look at the QRS complex of Lead I and Lead aVF

Is the QRS complex of Lead I more negative (downgoing or conduction away from the lead) or positive (upgoing or conduction towards the lead)?

Is the QRS complex of Lead aVF more negative or positive?

Cause of left axis deviation  Asd  Vsd  Normal Causes of right axis
Cause of left axis deviation
 Asd
 Vsd
 Normal
Causes of right axis deviation
 RVH
6.P Wave and PR Interval
 PR = beginning of P to beginning of QRS

P wave normal is 2-3 little squares (0.08-0.12);

wide P wave = left atrial enlargement

P wave is taller than 2-3 little squares = right atrial enlargement

PR is prolonged = first degree AV block-RF-digoxin

 PR is prolonged = first degree AV block-RF-digoxin  Second degree AV block (Mobitz I)

Second degree AV block (Mobitz I) with prolonged PR interval

Second degree AV block (Mobitz I) with prolonged PR interval 5 Visit us on
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Second degree heart block, Mobitz type I (Wenckeback phenomenon). Note how the baseline PR interval is prolonged, and then further prolongs with each successive beat, until a QRS complex is dropped.

Short PR interval=Preexcitation syndromes,AV nodal (junctional) rhythm. Preexcitation syndromes:

Wolff-Parkinson-White (WPW) and Lown-Ganong-Levine (LGL) syndromes.

These involve the presence of an accessory pathway connecting the atria and ventricles.

The accessory pathway conducts impulses faster than normal, producing a short PR interval.

Patients present with episodes of paroxsymal supraventricular tachycardia (SVT), specifically atrioventricular re-entry tachycardia (AVRT), and characteristic features on the resting 12-lead ECG. Wolff-Parkinson-White syndrome short PR interval, broad QRS and a slurred upstroke to the QRS complex, the delta wave.

a slurred upstroke to the QRS complex, the delta wave.  7.QRS Complex  If beginning

7.QRS Complex

If beginning of Q to end of S is longer than 2-3 small squares =

bundle branch block, hyperkalaemia or sodium-channel blockade

branch block, hyperkalaemia or sodium-channel blockade Look for the “M” sign in either V1 or V6

Look for the “M” sign in either V1 or V6

If the “M” is on V1 = Right bundle branch block (RBBB)

1. Aortic stenosis

2. Hypertension

3. Dilated cardiomyopathy

4. Hyperkalaemia

5. Digoxin toxicity

If the “M” is on V6 = Left bundle branch block (LBBB)

1. Right ventricular hypertrophy / cor pulmonale

2. Pulmonary embolus

3. Rheumatic heart disease

4. Myocarditis or cardiomyopathy

5. Congenital heart disease (e.g. atrial septal defect)

5. Congenital heart disease (e.g. atrial septal defect) 6 Visit us on
5. Congenital heart disease (e.g. atrial septal defect) 6 Visit us on
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8.QTc Interval

Beginning of Q to end of T

QT corrected interval for heart rate because as HR decrease, QT lengthens and vice versa

Normal: <0.45 (<6 months), <0.44 (>6 months)

QTc = QT / square root of RR interval

prolonged QT:

1. long QT syndrome

2. hypokalemia

3. hypomagnesemia

4. hypocalcemia

5. neurologic injury

3. hypomagnesemia 4. hypocalcemia 5. neurologic injury  Prolonged QT predisposes to ventricular tachycardia and

Prolonged QT predisposes to ventricular tachycardia and associated with sudden death

…………………………………………………………………………………

9.T wave

9.T wave  peaked, pointed T = hyperkalemia, LVH  flattened T

peaked, pointed T = hyperkalemia, LVH

flattened T waves = hypokalemia, hypothyroidism

LVH  flattened T waves = hypokalemia, hypothyroidism 10.Ventricular Hypertrophy Right ventricular hypertrophy 

10.Ventricular Hypertrophy

Right ventricular hypertrophy

R wave >98% in V1 or S wave >98% in I or V6

Increased R/S ratio in V1 or decreased R/S in V6

RSR’ in V1 or V3R in the absence of complete RBBB

Upright T wave in V1 (>3 days)

Presence of Q wave in V1, V3R, V4R

in V1 (>3 days)  Presence of Q wave in V1, V3R, V4R  causes of

causes of RVH: ASD, TAPVR, pulmonary stenosis, TOF, large VSD with pulmonary H

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Left ventricular hypertrophy  R >98% in V6, S >98% in V1  Increased R/S

Left ventricular hypertrophy

R >98% in V6, S >98% in V1

Increased R/S ratio in V6 or decreased R/S in V1

Q >5mm in V6 with peaked T

Causes: VSD, PDA, anemia, complete AV block, aortic stenosis, systemic HTN ………………………………………………………………………………………………………………………….

Fixed prolonged PR no missed beat Fixed prolonged PR with missed beat
Fixed prolonged
PR
no missed beat
Fixed prolonged
PR
with missed beat
variable prolonged PR no missed beat
variable
prolonged PR
no missed beat
Variable prolonged PR with missed beat
Variable
prolonged PR
with missed beat
PR no missed beat Variable prolonged PR with missed beat حاجنلاو قيفوتلاب-ءاعدلا حلاص نم

حاجنلاو قيفوتلاب-ءاعدلا حلاص نم انوسنتلا ريخلاب يلع.د

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