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 #2
Q 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 #3
Sinus 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 #4
ST 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 #5
RSR’
• 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 #7
RVH
• 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
ALCAPA
Anomalous Left Coronary Artery
from the Pulmonary Artery
Take home point #8
ST 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