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 (RR60-70),
  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
• HR125 RR42 O2sat94

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ECG
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Cardiologists Interpretation

• Sinus rhythm. Rate 124. QRS axis 150.PR 150ms.
  QRS 60ms. QT/QTc 240/340Bi-atrial hypertrophy,
  left gtrightRight 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 gt 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 RgtS 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 gt 2 mm tall in infants and small children
  and gt 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 gt 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 gt95 of normal S in V6 deeper than 95
  of normal

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Age HR bpm QRS axis degrees PR interval seconds QRS interval seconds R in V1 mm S in V1 mm R in V6 mm S in V6 mm
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
gt 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 RgtS) is prominent early and is
  normal
• RVH in kids
• 1. R in V1gt95 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