ECG Rounds:
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Transcript of ECG Rounds:
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ECG Rounds:Dr. Dave Dyck R3
April 3, 2003
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Case 1: 2 week infant with tachypnea (RR=60-70),
tachycardia (170) and “dusky” in appearance.
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Cardiologists Interpretation: Sinus rhythm. Heart Rate 160. QRS axis 90. PR 130ms. QRS 50ms. QT/QTc
280/450 Right atrial hypertrophy Right ventricular hypertrophy LV strain/ischaemia
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Of Note: The T wave changes are the most significant features of this
ECG.
An upright T wave in V1 in a 2 week old infant is abnormal and may signify RV systolic hypertension.
Inverted T waves in V5-6 are evidence of LV strain which may cause reciprocally upright T waves in the right chest leads.
(TGA/VSD/PA)
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Case 2: 13m female with failure to thrive and
worsening tachypnea sent to ER by GP HR=125 RR=42 O2sat=94%
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ECG:
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Cardiologist’s Interpretation: Sinus rhythm. Rate 124. QRS axis +150.
PR 150ms. QRS 60ms. QT/QTc 240/340Bi-atrial hypertrophy, left >rightRight axis deviationRight ventricular hypertrophy
(upright T waves in V1= abnormal)
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ECG:
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Of Note: This young child was born with a dysmorphic
mitral valve which has resulted in both mitral stenosis and incompetance.
The right sided hypertrophy is a result of pulmonary hypertension caused by her elevated left heart pressures.
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Pediatric ECGs Often 13 lead ECGs done (V3R or V4R) for
the evaluation of RVH in children
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V1 inverted Ts: 1st day = RAD, large R waves + upright T
waves in right precordial leads (V3R, V1) by 48 hrs: inverted T waves in V1, V3R
Upright Ts > 1 wk pathologic (RVH or strain)
Should never be upright before age 6 and often into adolescence
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Axis: Newborn Axis: usually +110 - +180 V1, V3R have R>S wave usually and often
for months/years (up to 8 yrs) Over the years, the QRS axis gradually shifts
leftward and right ventricular forces slowly regress
If it looks like a normal adult ECG early on think LVH
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Pediatric Heart Chamber Hypertrophy: Right Atrial Enlargement (RAE):
P wave > 2 mm tall in infants and small children and > 3 mm tall in older children
P waves best seen in inferior (I,II & aVF) and the right chest leads (V3R, V1 & V2)
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RAE:
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Left Atrial Enlargement: Wide P waves > 2 mm wide (.08s) in infants
and small children and more than 3 mm wide (.12s) in larger children
Best seen in inferolateral leads
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LAE:
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P wave morphology in AE:
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Right Ventricular Hypertrophy: R in V1 >95% of normal + S in V6 deeper than
95% of normal
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Age HRbpm
QRSaxis
degrees
PRintervalseconds
QRSintervalseconds
Rin V1mm
Sin V1mm
Rin V6mm
Sin V6mm
1st week 90-160 60-180 0.08-0.15 0.03-0.08 5-26 0-23 0-12 0-10
1-3wks 100-180 45-160 0.08-0.15 0.03-0.08 3-21 0-16 2-16 0-10
1-2 mo 120-180 30-135 0.08-0.15 0.03-0.08 3-18 0-15 5-21 0-10
3-5 mo 105-185 0-135 0.08-0.15 0.03-0.08 3-20 0-15 6-22 0-10
6-11 mo 110-170 0-135 0.07-0.16 0.03-0.08 2-20 0.5-20 6-23 0-7
1-2 yr 90-165 0-110 0.08-0.16 0.03-0.08 2-18 0.5-21 6-23 0-7
3-4 yr 70-140 0-110 0.09-0.17 0.04-0.08 1-18 0.5-21 4-24 0-5
5-7 yr 65-140 0-110 0.09-0.17 0.04-0.08 0.5-14 0.5-24 4-26 0-4
8-11 yr 60-130 -15-110 0.09-0.17 0.04-0.09 0-14 0.5-25 4-25 0-4
12-15 yr 65-130 -15-110 0.09-0.18 0.04-0.09 0-14 0.5-21 4-25 0-4
> 16 yr 50-120 -15-110 0.12-0.20 0.05-0.10 0-14 0.5-23 4-21 0-4
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RVH #2 rsR’ in V1 & V2 without a widened QRS duration
as in RBBB (note= 2nd R is larger)
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RVH #3 qR in V1 and V2
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RVH #4
Pure R in V1 & V2 +/- strain changes
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Left Ventricular Hypertrophy (LVH): S in V1 deeper than 95% of normal and R in V6
taller than 95% of normal
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Summary: From 5 days to age 6, upright T waves in V1 are
abnormal. RAD (& V3R, V1 R>S) is prominent early and is
normal RVH in kids
1. R in V1>95% of normal and S in V6 deeper than 95% 2. RsR’ in V1(2) without widened QRS 3. qR in V1(2) 4. pure R in V1(2) +/- strain
Ventricular hypertrophy in children is based on comparison to statistical norms