The ABC of Pediatric ECG

Transcription

1 The ABC of Pediatric ECG Mohamed Hamdan, MD, FAAP, FACC Assistant Professor of Pediatrics Columbia University College of Physicians and Surgeons, NY, USA Consultant Pediatric Cardiologist & Co-Director KidsHeart Medical Center Dubai-Abu Dhabi-Al Ain, UAE

2 Normal Values

3

4 GOLDEN RULE..!

5 Forget Internal Medicine!

6 14-Lead EKG 6 Limb leads I, II, III: Simple avf, avr, avl: Augmented 6 Chest leads V1-V6 2 Right Chest leads V3R, V4R

7 Nomenclature Right leads avr, V1, V3R, V4R Left Leads I, avl, V6 Inferior Leads II, III, avf Transitional Leads V2-V5 IGNORE

8 Practical Approach A) Age/ Calibration/ Speed B) LIMB LEADS C) CHEST LEADS 1. Rate 1. T waves (V1 & V6) 2. Axis (P& QRS) 2. R & S (V1 & V6) 3. NSR 3. RSR (V1) 4. P waves & PR interval (II) 4. ST Segments 5. Q waves (III) 5. QTc

9 A) Age/ Calibration/ Speed A.1) Speed: 25 mm/sec 1 small box = 0.04 sec (or 40 msec) 1 large box = 0.2 sec (or 200 msec) A.2) Calibration: 1 mv = 10 mm 1 small box = 1 mm (0.1 mv) ½ standard: 1 mv = 5 mm 1 small box = 0.2 mv (voltages x 2)

10 Full Standard Calibration

11 1/2 Standard Calibration

12 Electronic Interpretation GOOD for: rate, axis, intervals, RVH OK for: LVH BAD for: ST changes, Q waves, rhythm, QTc 12

13 10 yrs

14 B) Limb Leads 1. Rate 2. Axis (P&QRS) in I & avf 3. NSR 4. P-waves & PR interval (II) 5. Q-waves

15 Heart Rate / RR interval in msec. 1 small box = 0.04 sec = 40 mesc. The Box method 300/No. of large boxes 1500/No. of small boxes

16 B) Limb Leads 1. Rate 2. Axis (P&QRS) in I & avf 3. NSR 4. P-waves & PR interval (II) 5. Q-waves

17 B2) P-wave Axis Low LA Rhythm High LA Rhythm Low RA Rhythm Normal High RA Rhythm 0 P in Lead I +90 P in Lead avf

18 9 yrs + I Normal (High RA) + avf

19 6 yrs

20 6 yrs - avf Abnormal (Low RA) + I

21 B2) QRS Axis

22 QRS Axis NW Axis Superior Axis LAD LAD 0 Lead I RAD Normal Normal RAD Lead avf

23 Left Axis Deviation is NEVER normal (When QRS is ve in avf)

24 Causes of LAD in Pediatrics 1. AV canal (partial or complete) 2. Tricuspid atresia 3. WPW 4. Single ventricle 5. Left aneteior hemiblock 6. + LVH

25 20 months Left Axis Deviation

26 5 yrs Left axis deviation NW-axis

27 B) Limb Leads 1. Rate 2. Axis (P&QRS) (I & avf) 3. NSR (Normal Sinus Rhythm) 4. P-waves (II) 5. Q-waves

28 Normal Sinus Rhythm 1. Normal P-wave axis +ve in I & avf 2. One P : One QRS 3. Fixed P-wave morphology 4. Fixed PR interval I (+) avf (+)

29 2 yrs Normal sinus rhythm

30 7 yrs

31 7 yrs - avf Low RA rhythm + I

32 11 yrs

33 11 yrs Different P-wave axis Different P-wave morphology - avf + I Wandering Pacemaker

34 B) Limb Leads 1. Rate 2. Axis (P&QRS) (I & avf) 3. NSR 4. P-waves & PR interval (II) 5. Q-waves

35 B4) P-Waves Lead II Normal: 2.5 X 2.5 boxes 0.09 s X 2.5 mm Abnormal: RAE (P-pulmonale) LAE (P-mitrale)

36 2 month

37 2 yrs

38 B4) PR Interval Regardless the age: Normal (2-4 small squares) Prolonged PR 1 st - degree AV block: No clinical significance Common in: ASD, repaired TOF Short PR interval: WPW Pompe

39 B) Limb Leads 1. Rate 2. Axis (P&QRS) (I & avf) 3. NSR 4. P-waves & PR interval (II) 5. Q-waves

40 B5) Q-Waves Not infarction Ventricular septum Look for lead III value for age Normal: Inferior leads, avr & V6 Up to 1 box wide X 5 boxes height (0.04 sec X 5 mm) Abnormal: Leads I & avl Wide (> small square = 0.04 sec.) Deep ((> 95 th percentile for age) (ALCAPA) (Infarction) (LVH)

41 2 yrs 2 years

42 4 months LVH

43 7 months ALCAPA

44 C) Chest Leads 1. T-waves (V1 & V6) 2. RSR 3. R & S (V1 & V6) 4. ST segments 5. QTc

45 C) Chest Leads 1. T-waves (V1 & V6) 2. RSR 3. R & S (V1 & V6) 4. ST segments 5. QTc

46 C1) T-Waves AGE V 1 V 6 < 1 wk wk- adolescence - + > adolescence + +

47 1 day 1 day old Normal T-waves

48 3 months Normal T-waves

49 6 years Normal T-waves

50 15 yrs T-Waves Normal T-waves 3 wks

51 3 wks

52 3 wks Flat T-waves in V1: RVH

53 7 mo.

54 7 mo. +ve T-waves in V1: RVH

55 C) Chest Leads 1. T-waves (V1 & V6) 2. RSR (V1) 3. R & S (V1 & V6) 4. ST segments 5. QTc

56 C2) RSR Common in pediatrics: V 1 Can be: Normal RVH RBBB R R S

57 R R C2) RSR in V1 S QRS duration <= 0.08 sec sec > 0.09 sec Height of R'? Incomplete RBBB RBBB < 10 mm >= 10 mm Normal RVH

58 6 yrs Normal QRS= 0.07 sec

59 16 mo. QRS= 0.05 sec RVH

60 3 yrs RBBB

61 8 yrs QRS= 0.12 sec.

62 8 yrs QRS= 0.12 sec.

63 8 yrs QRS= 0.12 sec. RBBB

64 C) Chest Leads 1. T-waves (V1 & V6) 2. RSR (V1) 3. R & S (V1 & V6) 4. ST segments 5. QTc

65 8 yrs S1 &/or R6 >98%: LVH R & S Waves

66 Normal Values

67 Normal Values in Neonates Age HR PR QRS Axis QIII RV1 SV1 RV6 SV6 <1 m <150 ms <80 ms <5 mm <20 mm <10 mm <10 mm <10 mm

68 C) Chest Leads 1. T-waves (V1 & V6) 2. RSR (V1) 3. R & S (V1 & V6) 4. ST segments 5. QTc

69 2 days ST depression or elevation >1mm DDx: Pericarditis, Strain, Non-specific

70 C) Chest Leads 1. T-waves (V1 & V6) 2. RSR (V1) 3. R & S (V1 & V6) 4. ST segments 5. QTc

71 How to calculate QTc Interval? 1. Find a nice Q & T 2. Find regular HR 3. Measure Q-T (multiply by 0.04) & 4. Measure preceding RR (multiply by 0.04) 5. Bazzet s formula: QTc= QT / RR

72 Step-Wise Approach A) Age/ Calibration/ Speed B) Limb Leads 1. Rate 2. Axis (P&QRS) 3. NSR 4. P waves & PR interval (II) 5. Q waves (III) C) Chest Leads 1. T waves 2. RSR (V1) 3. R & S in (V1 & V6) 4. ST segments 5. QTc

73 Thank You