Download Teixeira

Otto Teixeira, MD
8/1/2010
Systematic interpretation
Be systematic!!
Otto HP Teixeira, MD, FRCPC, FAAP, FACC
ETSU Pediatric Cardiology
an academic practice of pediatric cardiology
Normal sinus rhythm
P wave before every QRS
QRS following every P
wave
Normal P wave axis
Normal PR interval is
NOT required
Rhythm
Rate
Axis
Intervals
Atrial enlargement
Ventricular hypertrophy
ST/T wave changes
P waved axis
Atrial depolarization occurs from SA node
Wave passes right to left, top to bottom
Positive deflections in leads I (right to left) and aVF
(top to bottom)
Inverted in aVR
Normal P wave axis = 0-90 degrees
P waved axis
Abnormal axis implies
ectopic pacemaker
Rate approximation
• Rate estimate: 300 - 150 - 75 - 60 50
• Easy to memorize
Positive in lead I,
negative in aVF
• 1500 / number of “little boxes”
Otto Teixeira, MD
Quadrant determination
8/1/2010
Left axis
Normal
axis
Left axis
“Boston”
Right axis
Axis < -5 degrees
Conduction abnormality
Associated with atrioventricular septal defect
May not correlate with LVH
Occurs in 5% of normal population
Extreme
R/L axis
(NNNNNN
NW“Seattle
”
Question # 1
This EKG shows a combination of:
Right axis
Axis > 100 degrees
“Normal for age”: rightward axis > 100 degrees, but
within normal limits for age (e.g. 2 week old with axis
of +140)
Suggestive of RVH
Intervals
1. Sinus rhythm
Left axis
2. Sinus rhythm
Right axis
PR Interval
Normal: .08-.16 sec
Varies between leads
Increases with age
Decreases with heart rate
Otto Teixeira, MD
8/1/2010
Prolonged PR
Short PR
Etiologies
Pre-excitation: Wolff-Parkinson-White, Lown-GanongLevine
Storage diseases (Pompe’s,Fabry disease, GM1
gangliosidosis)
Friedrich’s ataxia
Duchenne’s muscular dystrophy
= First degree AV block
Drugs
Atrial surgery (scar tissue)
Acute rheumatic fever (minor Jones criteria)
Kawasaki disease
QRS duration
QT Interval
Do NOT include U waves
Normal = 0.04 - 0.08 (may be up to 0.09 in
adolescents)
> 0.12 = bundle branch block
0.10-0.12: evaluate morphology
QT Interval
Do NOT include U waves
Normal < 0.44 sec
Normal < 0.44 sec
May be as high as 0.45 sec in adol/adult females
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.)
May be as high as 0.49 sec in newborns (to 6 mo.)
Pediatric ECGs
QT ruler may be helpful
Calculate:
QTC (Bazett’s formula) = QT/square root RR
Pediatric ECGs
Otto Teixeira, MD
8/1/2010
QT Abnormalities
Short QT
QT Abnormalities
Short QT
Digoxin
Hypercalcemia
Hypercalcemia
Long QT - Acquired
Metabolic
Digoxin
Long QT - Congenital
Drugs
LQTc syndromes:
CNS trauma
Jervell-Lange-Nielsen,
Romano-Ward
Myocardial
Pediatric ECGs
Atrial enlargement
Right atrial enlargement
Hypocalcemia
Hypomagnesemia
Malnutrition (anorexia)
Ischemia
Myocarditis
Pediatric ECGs
Atrial enlargement
Right atrial enlargement
P wave amplitude > 2.5
P wave amplitude > 2.5
mm in II (“pulmonale”)
Deep negative
deflection in first 0.04
seconds in chest leads
mm in II (“pulmonale”)
Deep negative
deflection in first 0.04
seconds in chest leads
Left atrial enlargement
Terminal portion of P
wave
Total duration > 0.10 sec
= 2.5 mm in II (“mitrale”)
Negative deflection in V1
> 1 mm
Pediatric ECGs
Atrial enlargement
Pediatric ECGs
Right ventricular hypertrophy
Mild
R’ > 15 mm (< 1 year) or > 10 mm (> 1 year)
Abnormal RSR’ of normal to slightly prolonged duration
in right chest leads
Pediatric ECGs
Pediatric ECGs
Otto Teixeira, MD
8/1/2010
Right ventricular hypertrophy
Mild
Severe
R’ > 15 mm (< 1 year) or > 10 mm (> 1 year)
Marked RAD
Abnormal RSR’ of normal to slightly prolonged duration
qR pattern V3R or V1
in right chest leads
Right ventricular hypertrophy
Moderate
R wave > 15 mm (any age) in right chest
Upright T wave > 3-5 days of age
Definite right axis deviation (non-RBBB)
Very tall R wave with ST depression and T
rR’ or R (no S) in right chest leads
Significant S in left chest leads
inversion in V1 (“strain”)
Deep S wave V6
Pediatric ECGs
Left ventricular hypertrophy
Pediatric ECGs
LVH with strain
Criteria
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
R/S in V1/V2 below normal
Deep/wide Q wave in V5/V6 >5 mm
Pediatric ECGs
Combined ventricular hypertrophy
Question # 2
This EKG shows:
Criteria
Positive voltage criteria for LVH and RVH
In absence of BBB, preexcitation
Positive voltage criteria for LVH or RVH with relatively
large voltages for the other ventricle
Large equiphasic QRS complexes in > 2 limb leads and
midprecordial (V2 - V5) leads:
“Katz-Wachtel phenomenon”
Pediatric ECGs
1. Sinus rhythm,
Right axis
LA enlargement
2. Left axis
RA enlargement
Bi-VH
Otto Teixeira, MD
Left axis, RAE, Combined VH
8/1/2010
Neonatal EKG
NSR with frequent PACs: common
Rate 110-160 bpm
QRS axis 10-180 degrees
QT prolongation common: 460 msec
RV dominance: R in V1 10-15mm ( > RVH)
deep S in V6 < 12mm
R/S > 1
• RSR’ may be normal
• T wave changes: up in V1 < 48 hs
(> 48 hs suggests RVH)
1 – 6 months
Normal ECG: 2day old infant
QRS axis rotates to leftward (less than +120)
R wave remains dominant in V1:
R/S ratio in V1 maybe >1 in V1 < 6mo
RSR’ pattern in V1 not abnormal
Sinus rhythm. Heart rate 130. Axis +135
PR 0.16. QRS 0.06. QT/QTc 0.28/0.41
Dominant RV voltages. Biphasic T wave V1-4
Question # 3
3 week old with cardiac failure
What does this ECG show?
1. Sinus rhythm
normal axis for age
RA and bi-V
enlargement
• 3. SVT
bi-atrial and bi-V
enlargement
3 week old with
cardiac failure
What does this ECG
show?
Sinus rhythm. Heart rate
135.
QRS axis +160
PR 120ms. QRS 60ms.
QT/QTc 280/420
RA enlargement,
Right ventricular
hypertrophy
Deep Q wave V5-6
suggests LVH
Abnormal repolarization
with ST elevation in
inferolateral leads
(From Dr. M. Tippel, Vancouver, BC).
Otto Teixeira, MD
8/1/2010
Conclusion
Be systematic!!!
Recommended references:
1.Davignon A, Rautaharju P, Boiselle E, Soumis F, Megelas M, Choquette A.
Normal ECG standards for infants and children. Pediatric Cardiology
1979;1:123-131
2.Emmanouilides GC, Moss AJ, Adams FH. The electrocardiogram in normal
newborn infants: correlation with hemodynamic observations. J Pediatr
1965;67:578-87
3.Sreenivasan VV, Fisher BJ, Liebman J, Downs TD. Longitudinal study of the
standard electrocardiogram in the healthy premature infant during the first year of
life. Am J Cardiol 1973;31:57-63
4.Garson A. Electrocardiography. In: Anderson RH, Macartney FJ, Shinebourne
EA, Tynan M eds. Paediatric Cardiology. Edinburgh; Churchill Livingstone,
1987:235-317
5.Garson. A. The Electrocardiogram in Infants and Children: A systematic
approach. Lea Feibiger, 1983
6.Myung K, Park MK, Guntheroth WG. How To Read Pediatric ECGs. St.
Louis, Mosby Year Book, 1992