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Introduction to Paedaitric ECG
Braja RayMD, MRCPCH, FRCPCH, CCT
Consultant Neonatologist and Paediatrician
Ex Consultant NHS EnglandAsst Prof
RKM Seva Pratisthan
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Electrophysiology
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Tracing
Small box = 1 x 1 mm Large box = 5 x 5 mm Amplitude = 10mm/1mv
Paper speed (horizontal boxes) Standard = 25 mm/sec
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Approach
Rhythm
Rate
Axis
Intervals
Atrial enlargement
Ventricular hypertrophy
ST/T wave evaluation
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Analyse this ECG
Rhythm, Rate, Axis, Intervals
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Rythms
Sinus rhythm
Tachyarrhythmia
Narrow complex 2 small squareWide complex - >2 small square
Bradyarrhythmia
Atrioventricular block
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Rate
60 / RR interval (in seconds)
300 / number of big boxes between
consecutive QRS complexes
1500 / number of little boxes between
consecutive QRS complexes
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Calculate the rates
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Sinus Rythm
P wave before every QRS
QRS following every P wave
Normal P wave axis Normal PR interval
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Torsa de
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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
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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
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Long PR
First degree AV block
Drugs
Atrial surgery (scar tissue) Acute rheumatic fever (minor Jones criteria)
Kawasaki disease
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Short PR
Wolff-Parkinson-White
Glycogen storage disease type IIa (Pompes)
Fabry disease
GM1 gangliosidosis
Friedrichs ataxia
Duchennes muscular dystrophy
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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
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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)
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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
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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
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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
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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
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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
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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
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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)
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RBBB: Etiologies
ASD/PAPVR
Right ventriculotomy
Ebsteins Coarctation (< 6 months)
LBBB
Rare in children
Seen in adults with ischemic and hypertensiveheart disease
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