Transcript EKG talk
Pediatric EKG Tuesday Noon Teaching Session Learning Objectives Basic Approach to Pediatric EKGs Rhythm recognition How to use the EKG machine Basic Approach to EKG interpretation What are some challenges to interpreting Pediatric EKG’s? What are some challenges to interpreting Pediatric EKG’s? • • age-related changes movement artifact How good are we at reading them? How good are we at reading them? • A study looking at the accuracy of EKG interpretation in the ED ‣ Discrepancy rates of 13-32% Horton LA, Mosee S, Brenner J. Use of the electrocardiogram in a pediatric emergency department. Arch Pediatr Adolesc Med 1994;148: 184-8. How commonly do we see EKG abnormalities? Horton LA, Mosee S, Brenner J. Use of the electrocardiogram in a pediatric emergency department. Arch Pediatr Adolesc Med 1994;148: 184-8. How commonly do we see EKG abnormalities? • Sample of EKG’s done in the ER Up to 20% had clinically significant findings Horton LA, Mosee S, Brenner J. Use of the electrocardiogram in a pediatric emergency department. Arch Pediatr Adolesc Med 1994;148: 184-8. and so, it’s important that we have a good approach to EKG interpretation and so, it’s important that we have a good approach to EKG interpretation Systemic and so, it’s important that we have a good approach to EKG interpretation Systemic Routine Let’s get started! Take a look at the settings • • Standard amplitude is ___ mm/mV Paper speed is ___ mm/s Double-check the settings • • Standard amplitude is 10 mm/mV Paper speed is 25 mm/s What do you check next? What do you check next? Rate Rhythm Axis What do you check next? Rate Rhythm Axis Age Rate Dubin, D. Rapid Interpretation of EKG’s. 6th Edition. Tampa, FL: Cover Publishing; 2000: 80-84. Rate Dubin, D. Rapid Interpretation of EKG’s. 6th Edition. Tampa, FL: Cover Publishing; 2000: 80-84. Rate Dubin, D. Rapid Interpretation of EKG’s. 6th Edition. Tampa, FL: Cover Publishing; 2000: 80-84. Rate Dubin, D. Rapid Interpretation of EKG’s. 6th Edition. Tampa, FL: Cover Publishing; 2000: 80-84. Rate Dubin, D. Rapid Interpretation of EKG’s. 6th Edition. Tampa, FL: Cover Publishing; 2000: 80-84. Rate Dubin, D. Rapid Interpretation of EKG’s. 6th Edition. Tampa, FL: Cover Publishing; 2000: 80-84. Rate Dubin, D. Rapid Interpretation of EKG’s. 6th Edition. Tampa, FL: Cover Publishing; 2000: 80-84. Rate 1.2 seconds 6 big boxes 3 cycles Rate 3 cycles Rate 1.2 seconds x 50 = ___ cycles/min 3 cycles x 50 = 150 ___ cycles/min 1.2 seconds Rhythm • What defines a sinus rhythm? P wave before every QRS QRS after every P wave ‣ Normal PR interval for age Normal P wave axis Upright I and aVF Rhythm • What defines a sinus rhythm? P wave before every QRS QRS after every P wave Normal PR interval for age Normal P wave axis Upright I and aVF Axis “Two Left Feet” Which quadrant represents a “normal” QRS axis in an adult? Where would you see Left Axis Deviation? Left Axis Deviation What would this be? Extreme Right Axis Deviation And this? Right Axis Deviation Axis • QRS axis is usually directed toward a hypertrophied ventricle ‣ What is the expected axis in a newborn? Axis • What is the expected axis in a newborn? Large R ventricle = Right axis deviation Newborn - R-wave will be increased in V1 and V2 and decreased in V5 and V6 Normal neonatal EKG in a 1-week-old infant. QRS axis is 125°, which would be considered right axis deviation in an adult. Note the tall R waves in V1, V2, and V3, which are normal. O’Connor, M., McDaniel, N., Brady, W. The Pediatric Electrocardiogram Part I: Age-related Interpretation. American Journal of Emergency Medicine (2008) 26, 221–228 What comes next? Rate Rhythm Axis What comes next? Rate Rhythm Axis Waves and Intervals Hypertrophy or Enlargement Conduction Disturbance What comes next? Rate Rhythm Axis Waves and Intervals Hypertrophy or Enlargement Conduction Disturbance Normal Intervals Sharieff GQ, Rao SO. The pediatric EKG. Emerg Med. Clin North Am 2006;24:196. Some trends to consider • QRS Interval shorter than in adults Some trends to consider • QRS Interval shorter than in adults Sharieff GQ, Rao SO. The pediatric EKG. Emerg Med. Clin North Am 2006;24:196. Some trends to consider • PR Interval shorter in children and increases with age Sharieff GQ, Rao SO. The pediatric EKG. Emerg Med. Clin North Am 2006;24:196. Some trends to consider • T waves At birth - upright, flat or inverted Few days old - inverted • upright T-waves can indicate RVH T-wave inversion can be seen in V1V3 typically until 8 years of age (but can persist into early adolescence) T wave inversion in a 5 year old. Is this normal? Figure 1. 12-lead EKG of 5-year-old girl demonstrating normal sinus rhythm at a rate of 112 beats/min and inverted T waves in leads V1, V2, and V3 Chan, T., Sharieff, G., Brady, W. Electrocardiographic Manifestations: Pediatric EKG. Journal of Emergency Medicine. 35(4):421–430 • Some trends to consider T waves At birth - upright, flat or inverted Few days old - inverted • upright T-waves can indicate RVH T-wave inversion can be seen in V1V3 typically until 8 years of age (but can even persist into early adolescence) Chan, T., Sharieff, G., Brady, W. Electrocardiographic Manifestations: Pediatric EKG. Journal of Emergency Medicine. 35(4):421–430 QT interval • Varies with heart rate ‣ need to correct for heart rate QT interval QT interval 6 boxes QT interval 9 boxes 6 boxes QT interval 9 boxes How long are each of these intervals? 6 boxes QT interval 9 boxes One little box is ___ seconds 6 boxes QT interval 9 boxes One little box is 0.04 seconds 25mm 1 second 6 boxes = 1 mm 0.04 sec QT interval 9 boxes x 0.04 = 0.36 s 6 boxes x 0.04 = 0.24 s 9 boxes x 0.04 = 0.36 s 6 boxes x 0.04 = 0.24 s QT interval QTc= QT √RR Bazett’s formula 9 boxes x 0.04 = 0.36 s QT interval QTc= QT √RR QTc= 0.24 √0.36 6 boxes x 0.04 = 0.24 s 9 boxes x 0.04 = 0.36 s QT interval QTc= QT √RR QTc= 0.24 √0.36 6 boxes x 0.04 = 0.24 s QT c= 0.4 s 9 boxes x 0.04 = 0.36 s QT interval QTc= QT √RR QTc= 0.24 √0.36 6 boxes x 0.04 = 0.24 s QT c= 400 milliseconds QTc interval • What is the upper limit of normal? ‣ _____ in infants < 6 months ‣ _____ for other age groups QT interval • What is the upper limit of normal? ‣ 490 ms in infants < 6 months ‣ 440 ms for other age groups O’Connor, M., McDaniel, N., Brady, W. The Pediatric Electrocardiogram Part I: Age-related Interpretation. American Journal of Emergency Medicine (2008) 26, 221–228 Trivia - Name 2 congenital long QT syndromes • ‣ autosomal dominant ‣ autosomal recessive, associated with congenital deafness • Trivia - Name 2 congenital long QT syndromes • Romano-Ward Syndrome ‣ autosomal dominant (1:7000) ‣ autosomal recessive, associated with congenital deafness Trivia - Name 2 congenital long QT syndromes • Romano-Ward Syndrome ‣ • autosomal dominant (1:7000) Jervell-Lange-Nielsen Syndrome ‣ autosomal recessive ‣ congenital deafness Acquired causes of prolonged QT Acquired causes of prolonged QT • medications • • • • • • • www.qtdrugs.org hypokalemia hypomagnesemia hypocalcemia starvation, anorexia nervosa connective tissue disease sinus node dysfunction, AV block ...and other causes Rate Rhythm Axis Waves and Intervals Hypertrophy or Enlargement Conduction Disturbance Hypertrophy • RVH Hypertrophy R in V1 or S in V6 > 98th %ile RSR’ pattern in lead V1 ‣ R’ height being greater than 15 mm in infants younger than 1 year of age or greater than 10 mm in children older than 1 year of age Right axis deviation Upright T in V1 after Day 3 of life Q in V1(qR or qRs pattern) Sharieff GQ, Rao SO. The pediatric EKG. Emerg Med. Clin North Am 2006;24:196. RVH Fig. 11 Right ventricular hypertrophy in a 10-year-old male with primary pulmonary hypertension. Note the tall R waves in V1 and V2 and the deep S waves in V5 and V6. Right axis deviation is also present. O’Connor, M., McDaniel, N., Brady, W. The Pediatric Electrocardiogram Part I: Age-related Interpretation. American Journal of Emergency Medicine (2008) 26, 221–228 Normal adolescent male Hypertrophy • LVH R in V5 or V6 > 98th %ile R less than 5th %ile in V1 or V2 S in V1 > 98th %ile Q wave greater than 4 mm in lead V5 or V6 Inverted T wave in lead V6 Left axis deviation Sharieff GQ, Rao SO. The pediatric EKG. Emerg Med. Clin North Am 2006;24:196. LVH Left ventricular hypertrophy in a 3-year-old boy with unrepaired coarctation of the aorta. Note the deep S waves in V1 and V2 with tall R waves in V4 and V5. O’Connor, M., McDaniel, N., Brady, W. The Pediatric Electrocardiogram Part I: Age-related Interpretation. American Journal of Emergency Medicine (2008) 26, 221–228 Normal 4 year old male O’Connor, M., McDaniel, N., Brady, W. The Pediatric Electrocardiogram Part I: Age-related Interpretation. American Journal of Emergency Medicine (2008) 26, 221–228 T-wave Axis T-wave Axis • Any T-wave axis outside of 0 to +90 is ABNORMAL ‣ severe ventricular hypertrophy (strain) ‣ conduction disturbances ‣ metabolic abnormality ‣ ischemia Atrial Enlargement Atrial Enlargement Atrial Enlargement Atrial Enlargement And how about this one? Atrial Enlargement Atrial Enlargement Rhythm Recognition For each of the following: • Too fast? • Too slow? • Rhythm? ventricular tachycardia (monomorphic) patient does not have detectable pulses Pulseless Electrical Activity (PEA) 8 year old boy, HR 55 BPM Sinus Bradycardia Asystole 3 y o child, HR 188 Sinus tachycardia Supraventricular tachycardia 8 year old boy, HR 75 BPM Sinus Rhythm Ventricular Fibrillation with Successful Defibrillation 9 month old, HR 38 Sinus bradycardia and first-degree AV block Second Degree AV Block, Type 1 O’Connor, M., McDaniel, N., Brady, W. The Pediatric Electrocardiogram Part I: Age-related Interpretation. American Journal of Emergency Medicine (2008) 26, 221–228 Second Degree AV Block, Type 2 Third Degree AV Block O’Connor, M., McDaniel, N., Brady, W. The Pediatric Electrocardiogram Part I: Age-related Interpretation. American Journal of Emergency Medicine (2008) 26, 221–228 Torsades de pointes 3 year old with a known abnormality in his intraventricular conduction system SVT with aberrant intraventricular conduction Supraventricular tachycardia treated with adenosine Hyperkalemia Hypokalemia Flattened or inverted T-waves U wave Hypokalemia Flattened or inverted T-waves U wave increased PR interval decreased ST segment Learning Objectives Basic Approach to Pediatric EKGs • • systematic approach refer to tables with age-related values Rhythm recognition How to use the EKG machine The End Any questions? References • Chan, T., Sharieff, G., Brady, W. Electrocardiographic Manifestations: Pediatric EKG. Journal of Emergency Medicine. 35(4):421–430 • Dubin, D. Rapid Interpretation of EKG’s. 6th Edition. Tampa, FL: Cover Publishing; 2000: 80-84. • O’Connor, M., McDaniel, N., Brady, W. The Pediatric Electrocardiogram Part I: Age-related Interpretation. American Journal of Emergency Medicine (2008) 26, 221–228 • Sharieff GQ, Rao SO. The pediatric EKG. Emerg Med. Clin North Am 2006;24:196. • • Pediatric Advanced Life Support, 2006 Edition. Wathen JE, Rewers AB, Yetman AT, et al. Accuracy of EKG interpretation in the pediatric emergency department. Ann Emerg Med. 2005;46:507-11.