Approach to Pediatric Approach to Pediatric ECGECG

September 22, 2005September 22, 2005

Sultana QureshiSultana Qureshi

IndicationsIndications Definitely:Definitely:

SyncopeSyncope Exertional symptomsExertional symptoms Tachycardia/BradycardiaTachycardia/Bradycardia PalpitationsPalpitations

ECG not as useful in isolated chest pain in kidsECG not as useful in isolated chest pain in kids

Other indicationsOther indications::

• Seizure

• Drug ingestion

• Heart failure

• Cyanotic Episodes

• Hypothermia

• Electrolyte disturbance

• Kawasaki Disease

• Rheumatic Fever

• Myocarditis/Pericarditis

• Congenital Heart Disease

• Myocardial Contusion

• Post cardiac surgery

Pediatric ECG findings Pediatric ECG findings that may be normalthat may be normal

Heart Heart RateRate >100 bpm >100 bpm

Sinus ArrythmiaSinus Arrythmia

QRS QRS AxisAxis >+90 >+90°°

Shorter Shorter intervalsintervals (PR, QT, duration of QRS, (PR, QT, duration of QRS,

etc)etc)

T-waveT-wave inversion of right precordial leads inversion of right precordial leads

Dominant Right precordial Dominant Right precordial R-wavesR-waves

Q-wavesQ-waves (inferior and lateral leads) (inferior and lateral leads)

ST elevationST elevation due to early repolarization due to early repolarization

Development of the HeartDevelopment of the Heart (Relative to ECG findings)(Relative to ECG findings)

At BirthAt Birth Thickness of RV > LVThickness of RV > LV ECG = RAD (60ECG = RAD (60°-160°) & °-160°) &

= RV dominance in precordial leads= RV dominance in precordial leads

= T-wave upright in V= T-wave upright in V11--VV3 3

6 months6 months Adult proportions of ventriclesAdult proportions of ventricles ECG = LV dominanceECG = LV dominance

= T-wave inverted in V= T-wave inverted in V11-V-V3 3 1 year1 year

QRS Axis 10° - 100 ° QRS Axis 10° - 100 °

Pulmonary vascular resistance

Systemic Vascular Resistance

Step 1: IdentifyStep 1: Identify

AGE!

Approach to Pediatric ECGApproach to Pediatric ECG

Step 2: Heart RateStep 2: Heart Rate

Approach to Pediatric ECGApproach to Pediatric ECG

TABLE 164-2 -- Age-Specific Rates

Age

Beats per minute  

Range (degrees) Mean  

First week 100–175 130  

1 week to 3 months 85–190 160  

3–12 months 110–180 140  

1–3 years 98–163 126  

3–5 years 65–132 98  

5–8 years 70–115 96  

8–16 years 55–107 79  

Rosen (2005)

Step 2: Heart RateStep 2: Heart Rate

Approach to Pediatric ECGApproach to Pediatric ECG

Step 2: Heart RateStep 2: Heart Rate

Approach to Pediatric ECGApproach to Pediatric ECG

Sinus Arrythmia

• more common and profound in children

• clinical correlation

Step 3: RhythmStep 3: Rhythm

Approach to Pediatric ECGApproach 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

Step 3: RhythmStep 3: Rhythm

Approach to Pediatric ECGApproach to Pediatric ECG

Age HRbpm

QRSaxis

degrees

PRinterva

lsecond

s

QRSintervalseconds

Rin V1mm

Sin V1mm

Rin V6mm

SIn

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

> 16 yr 50-120 -15-110 0.12-0.20

0.05-0.10 0-14 0.5-23 4-21 0-4

Step 4: QRS AxisStep 4: QRS AxisApproach to Pediatric ECGApproach to Pediatric ECG

3 days old 12 years old

Step 4: QRS AxisStep 4: QRS AxisApproach to Pediatric ECGApproach to Pediatric ECG

TABLE 164-5 -- Age-Specific QRS Axis (Frontal Plane)

AgeRange

(degrees)Mean

(degree)

1–7 days 80–160 125

1–4 weeks 30–180 110

1–3 months 10–125 70

3–6 months 20–80 65

6–12 months

0–100 65

1–3 years 20–100 55

3–8 years 20–120 60

Step 5: Specific WaveformsStep 5: Specific Waveforms

Large right precordial Large right precordial R-waves R-waves (RV dominance)(RV dominance)

T-waveT-wave inversion of V inversion of V11- V- V33, V, V44RR Juvenile T wave variantJuvenile T wave variant (normal from 7d- 7y) (normal from 7d- 7y)

Abnormal if T-waves upright between 7d -7y, and indicator Abnormal if T-waves upright between 7d -7y, and indicator

of RVH (even if do not meet voltage criteria for RVH)of RVH (even if do not meet voltage criteria for RVH)

Q-wavesQ-waves (inferior and lateral leads) (inferior and lateral leads)

ST elevationST elevation from Early Repolarization, and J- from Early Repolarization, and J-

point depressionpoint depression

Approach to Pediatric ECGApproach to Pediatric ECG

Step 5: Specific WaveformsStep 5: Specific WaveformsApproach to Pediatric ECGApproach to Pediatric ECG

3 days old 12 years old

Normal Adult ECG

Step 5: Specific WaveformsStep 5: Specific Waveforms

Approach to Pediatric ECGApproach to Pediatric ECG

Young AdultYoung Adult

2 weeks old2 weeks old

Pediatric ECG findings Pediatric ECG findings that may be normalthat may be normal

Heart Heart RateRate >100 bpm >100 bpm

Sinus ArrythmiaSinus Arrythmia

QRS QRS AxisAxis >+90 >+90°°

Shorter Shorter intervalsintervals (PR, QT, duration of QRS, (PR, QT, duration of QRS,

etc)etc)

T-waveT-wave inversion of right precordial leads inversion of right precordial leads

Dominant Right precordial Dominant Right precordial R-wavesR-waves

Q-wavesQ-waves (inferior and lateral leads) (inferior and lateral leads)

ST elevationST elevation due to early repolarization due to early repolarization