introduction to paedaitric ecg

8/2/2019 Introduction to Paedaitric ECG

1/49

Introduction to Paedaitric ECG

Braja RayMD, MRCPCH, FRCPCH, CCT

Consultant Neonatologist and Paediatrician

Ex Consultant NHS EnglandAsst Prof

RKM Seva Pratisthan


2/49

Electrophysiology


3/49


4/49

Tracing

Small box = 1 x 1 mm Large box = 5 x 5 mm Amplitude = 10mm/1mv

Paper speed (horizontal boxes) Standard = 25 mm/sec


5/49


6/49

Approach

Rhythm

Rate

Axis

Intervals

Atrial enlargement

Ventricular hypertrophy

ST/T wave evaluation


7/49

Analyse this ECG

Rhythm, Rate, Axis, Intervals


8/49

Rythms

Sinus rhythm

Tachyarrhythmia

Narrow complex 2 small squareWide complex - >2 small square

Bradyarrhythmia

Atrioventricular block


9/49


10/49


11/49

Rate

60 / RR interval (in seconds)

300 / number of big boxes between

consecutive QRS complexes

1500 / number of little boxes between

consecutive QRS complexes


12/49


13/49


14/49

Calculate the rates


15/49

Sinus Rythm

P wave before every QRS

QRS following every P wave

Normal P wave axis Normal PR interval


16/49


17/49


18/49


19/49


20/49


21/49


22/49

Torsa de


23/49


24/49


25/49


26/49

Axis determination

Amplitude vector

Add net R-S in lead I, R-S in aVF

Plot in mm on grid (lead I horizontal, lead aVFvertical)

Draw vector from origin to net amplitude

Angle of vector = axis


27/49


28/49

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


29/49


30/49


31/49

Long PR

First degree AV block

Drugs

Atrial surgery (scar tissue) Acute rheumatic fever (minor Jones criteria)

Kawasaki disease


32/49

Short PR

Wolff-Parkinson-White

Glycogen storage disease type IIa (Pompes)

Fabry disease

GM1 gangliosidosis

Friedrichs ataxia

Duchennes muscular dystrophy


33/49

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


34/49

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)


35/49


36/49

Long QT

Onset of ventricular depolarization (Q wave) toend 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


37/49

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


38/49

Atrial enlargement

Right atrial enlargement

P wave amplitude > 2.5

mm in II

Deep negativedeflection in first 0.04

seconds in chest leads

Left atrial enlargement

Terminal portion of P

wave

Negative deflection inV1 beyond 0.04 sec

Duration of negative

deflection > 0.04 sec

Total duration > 0.10

sec


39/49


40/49


41/49

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


42/49

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


43/49


44/49

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


45/49

RBBB

Prolongation in terminal phase of QRS (terminalslurring

Delayed conduction through RBB prolongsdepolarization 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)


46/49

RBBB: Etiologies

ASD/PAPVR

Right ventriculotomy

Ebsteins Coarctation (< 6 months)

LBBB

Rare in children

Seen in adults with ischemic and hypertensiveheart disease


47/49


48/49


49/49

introduction to paedaitric ecg

Documents