Pediatrics ECG

By Dr ali bel kheir

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Electrocardiography
Electricity of the heart

Atrial contractions P wave

Ventricular contractions QRS complex
Ventricular repolarizations T wave
2 interval ( PR&QT)
2 segment (PQ&ST)
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Precordial leads:
V4R: 5th intercostal space, right midclavicular line
V1: 4th intercostal space, right sternal border
V2: 4th intercostal space, left sternal border
V3: use this lead for V4R, must label as such on ECG.
V4: fifth intercostal space, right midclavicular line
V5: anterior axillary line, same horizontal plane as V4
V6: midaxillary line, same horizontal line as V4.
Limb leads: Place on top part of arm or leg (less muscle interference).
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Common Findings on the Paediatric ECG

The following electrocardiographic features may be normal in children:
Heart rate >100 beats/min
Rightward QRS axis > +90
T wave inversions in V1-3 (juvenile T-wave pattern)
Dominant R wave in V1
Marked sinus arrhythmia
Short PR interval (< 120ms) and QRS duration (<80ms)
Slightly peaked P waves (< 3mm in height is normal if 6 months)
Slightly long QTc ( 490ms in infants 6 months)
Q waves in the inferior and left precordial leads.

1. First things first

Check the name on the top of the ECG is this your patient?
Check the date is this the one you ordered?
Check for the age of the patient the heart physiology and the
normal values differ in different age groups in the pediatric population
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2. Technical Aspects
a) Is the ECG full standard?
Full standard means that the ECG was not reduced in size so that it can fit on
the paper
Look at the left hand side of each line
If it is full standard, the rectangles height should be 2 big squares
If it is half standard, the rectangles height is only 1 big square You will
need to double all the waves to normalize them
b) What is the paper speed?
The standard speed is 25mm/sec
That means :
each little box is 0.04 seconds
each big box is 0.2 seconds
5 large box=25 mm=1 seconds

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3. Rate
a) Normal, Fast or Regular Rates
Find 2 adjacent R waves, count the number of big squares between the Rs
Divide 300 by the number of big squares this is your rate

b) Slow or Irregular Rates

The easiest way to calculate the rate is to count the total number of
QRS complex along the length of the entire strip and multiply it by 10 = this
is your rate (bpm)
Note: The normal value for heart rate ranges dramatically depending on
your patients agecheck tablet at end
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4. Rhythm
a) Analysis
Is the rhythm sinus?
Sinus rhythm:
Is there a P wave before each QRS complex?
Is there a QRS complex after every P wave?
Are the P waves upright in leads I, II, III?
Do all P waves should look the same?
Are all P wave axis normal (0 to +90)?
Are the PR intervals constant?

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 Is the rhythm regular or irregular? Do the P waves and QRS follow a

regular pattern?
If it is irregular, is it consistently irregular or consistently irregular?
b) Abnormal Rhythms
Atrial Flutter Rapid atrial rate (~300 bpm)
with varying ventricular rate
Sawtooth pattern
Suggests significant pathology
Atrial
Very fast atrial rate (350-600
Fibrillation
bpm)
Irregularly irregular
No P waves, normal QRS
Suggests significant pathology
Ventricular
Wide, unusually shaped QRS
Tachycardia T waves opposite direction of
QRS
HR 120-200 bpm
Suggests significant pathology
Ventricular
Very irregular QRS
Fibrillation
Rate is rapid and irregular
terminal arrhythmia

Premature
Atrial
Contraction
(PAC)

Length of two cycles (R-R)

usually shorter
Preceded by P wave, followed
by normal QRS
No hemodynamic significance

Premature
Ventricular
Contraction
(PVC)

Premature, wide QRS, no P

waves, T wave opposite to

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5. Axis
Axis is the conduction flow of the heart
Normal axis varies with age i.e. newborns have a right axis deviation
because the left and right ventricles are the same size due to fetal circulation
Look at the QRS complex of Lead I and Lead aVF
Is the QRS complex of Lead I more negative (downgoing or conduction away
from the lead) or positive (upgoing or conduction towards the lead)?
Is the QRS complex of Lead aVF more negative or positive?

Cause of left axis deviation

Causes of right axis deviation

Asd
Vsd
Normal
RVH

6.P Wave and PR Interval

PR = beginning of P to beginning of QRS
P wave normal is 2-3 little squares (0.08-0.12);
wide P wave = left atrial enlargement
P wave is taller than 2-3 little squares = right atrial enlargement
PR is prolonged = first degree AV block-RF-digoxin

Second degree AV block (Mobitz I) with prolonged PR interval

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Second degree heart block, Mobitz type I (Wenckeback phenomenon). Note how the
baseline PR interval is prolonged, and then further prolongs with each successive beat, until
a QRS complex is dropped.

Short PR interval=Preexcitation syndromes,AV nodal (junctional) rhythm.

Preexcitation syndromes:
Wolff-Parkinson-White (WPW) and Lown-Ganong-Levine (LGL) syndromes.
These involve the presence of an accessory pathway connecting the atria
and ventricles.
The accessory pathway conducts impulses faster than normal, producing a
short PR interval.
Patients present with episodes of paroxsymal supraventricular tachycardia
(SVT), specifically atrioventricular re-entry tachycardia (AVRT), and
characteristic features on the resting 12-lead ECG.
Wolff-Parkinson-White syndrome
short PR interval, broad QRS and a slurred upstroke to the QRS complex, the
delta wave.

7.QRS Complex
If beginning of Q to end of S is longer than 2-3 small squares =
bundle branch block, hyperkalaemia or sodium-channel blockade
Look for the M sign in either V1 or V6
If the M is on V1 = Right bundle branch block (RBBB)
1. Aortic stenosis
2. Hypertension
3. Dilated cardiomyopathy
4. Hyperkalaemia
5. Digoxin toxicity
If the M is on V6 = Left bundle branch block (LBBB)
1. Right ventricular hypertrophy / cor pulmonale
2. Pulmonary embolus
3. Rheumatic heart disease
4. Myocarditis or cardiomyopathy
5. Congenital heart disease (e.g. atrial septal defect)
6

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8.QTc Interval
Beginning of Q to end of T
QT corrected interval for heart rate because as HR decrease, QT lengthens
and vice versa
Normal: <0.45 (<6 months), <0.44 (>6 months)
QTc = QT / square root of RR interval
prolonged QT:
1. long QT syndrome
2. hypokalemia
3. hypomagnesemia
4. hypocalcemia
5. neurologic injury
Prolonged QT predisposes to ventricular tachycardia and associated with
sudden death

9.T wave
peaked, pointed T = hyperkalemia, LVH
flattened T waves = hypokalemia, hypothyroidism

10.Ventricular Hypertrophy
Right ventricular hypertrophy
R wave >98% in V1 or S wave >98% in I or V6
Increased R/S ratio in V1 or decreased R/S in V6
RSR in V1 or V3R in the absence of complete RBBB
Upright T wave in V1 (>3 days)
Presence of Q wave in V1, V3R, V4R

causes of RVH: ASD, TAPVR, pulmonary stenosis, TOF, large VSD with
pulmonary H

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Left ventricular hypertrophy

R >98% in V6, S >98% in V1
Increased R/S ratio in V6 or decreased R/S in V1
Q >5mm in V6 with peaked T
Causes: VSD, PDA, anemia, complete AV block, aortic stenosis, systemic HTN
.

Fixed prolonged
PR
no missed beat

variable
prolonged PR
no missed beat

Fixed prolonged
PR
with missed beat

Variable
prolonged PR
with missed beat

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.
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