Pediatric ECGs: Difference between revisions
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Left axis deviation | Left axis deviation | ||
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==Conduction== | ==Conduction: definition of LBBB and RBBB in children== | ||
RBBB: if consistent morphology and if QRS width >90ms in children < 4 years and >100ms in children 4-16 years<cite>aha</cite> | *'''RBBB''': if consistent morphology and if QRS width >90ms in children < 4 years and >100ms in children 4-16 years<cite>aha</cite> | ||
LBBB: if consistent morphology and QRS width >90ms in children < 4 years and >100ms in children 4-16 years<cite>aha</cite> | *'''LBBB''': if consistent morphology and QRS width >90ms in children < 4 years and >100ms in children 4-16 years<cite>aha</cite> | ||
==Normal neonatal ECG standards== | ==Normal neonatal ECG standards== | ||
{| class="wikitable" font-size="80%" width="100%" style="border:1px solid #E2ACB1;border-spacing:8px;" border="1" | {| class="wikitable" font-size="80%" width="100%" style="border:1px solid #E2ACB1;border-spacing:8px;" border="1" | ||
|+Normal neonatal ECG standards | |+Normal neonatal ECG standards<cite>schwarz1</cite> | ||
! style="width:70px" | Age group | ! style="width:70px" | Age group | ||
! style="width:90px" | Heart rate<br/>(beats . min<sup>-1</sup>) | ! style="width:90px" | Heart rate<br/>(beats . min<sup>-1</sup>) | ||
! style="width:105px" | Frontal plane<br/>QRS axis<sup>a</sup><br/>(degrees) | ! style="width:105px" | Frontal plane<br/>QRS axis<sup>a</sup><br/>(degrees) | ||
! style="width: | ! style="width:65px" | P wave<br/>amplitude<br/>(mm) | ||
! style="width:100px" | P-R<br/>interval<sup>a</sup><br/>(s) | ! style="width:100px" | P-R<br/>interval<sup>a</sup><br/>(s) | ||
! style="width:100px" | QRS<br/>duration<sup>a</sup><br/>V<sub>5</sub> | ! style="width:100px" | QRS<br/>duration<sup>a</sup><br/>V<sub>5</sub> | ||
| Line 87: | Line 87: | ||
! style="width:40px" | RV<sub>1</sub><sup>b</sup> (mm) | ! style="width:40px" | RV<sub>1</sub><sup>b</sup> (mm) | ||
! style="width:40px" | SV<sub>1</sub><sup>b</sup> (mm) | ! style="width:40px" | SV<sub>1</sub><sup>b</sup> (mm) | ||
!R/S V<sub>1</sub><sup>c</sup> | ! style="width:50px" | R/S V<sub>1</sub><sup>c</sup> | ||
! style="width:40px" | RV<sub>6</sub><sup>b</sup> (mm) | ! style="width:40px" | RV<sub>6</sub><sup>b</sup> (mm) | ||
! style="width:40px" | SV<sub>6</sub><sup>b</sup> (mm) | ! style="width:40px" | SV<sub>6</sub><sup>b</sup> (mm) | ||
!R/S V<sub>6</sub><sup>c</sup> | ! style="width:50px" | R/S V<sub>6</sub><sup>c</sup> | ||
!SV<sub>1</sub> + RV<sub>6</sub><sup>c</sup> (mm) | ! style="width:70px" | SV<sub>1</sub> + RV<sub>6</sub><sup>c</sup> (mm) | ||
!R + SV<sub>4</sub><sup>c</sup> (mm) | ! style="width:70px" | R + SV<sub>4</sub><sup>c</sup> (mm) | ||
|- | |- | ||
|0–1 days | |0–1 days | ||
| Line 112: | Line 112: | ||
|- | |- | ||
| | |1–3 days | ||
| align="center" | 91–159 (123) | |||
| align="center" | +64 to +197 (134) | |||
| align="center" | 2·8 | |||
| align="center" | 0·08–0·14 (0·11) | |||
| align="center" | 0·02–0·07 (0·05) | |||
| align="center" | 5·2 | |||
| align="center" | 2·1 | |||
| align="center" | 5–27 | |||
| align="center" | 0–21 | |||
| align="center" | 6 | |||
| align="center" | 0–12 | |||
| align="center" | 0–9·5 | |||
| align="center" | 11 | |||
| align="center" | 29 | |||
| align="center" | 52 | |||
|- | |- | ||
| | |3–7 days | ||
| align="center" | 90–166 (129) | |||
| align="center" | +77 to +187 (132) | |||
| align="center" | 2·9 | |||
| align="center" | 0·08–0·14 (0·10) | |||
| align="center" | 0·02–0·07 (0·05) | |||
| align="center" | 4·8 | |||
| align="center" | 2·8 | |||
| align="center" | 3–24 | |||
| align="center" | 0–17 | |||
| align="center" | 9·7 | |||
| align="center" | 0·5–12 | |||
| align="center" | 0–9·8 | |||
| align="center" | 10 | |||
| align="center" | 25 | |||
| align="center" | 48 | |||
|- | |- | ||
|7 | |7–30 days | ||
| align="center" | 107–182 (149) | |||
| align="center" | +65 to +160 (110) | |||
| align="center" | 3·0 | |||
| align="center" | 0·07–0·14 (0·10) | |||
| align="center" | 0·02–0·08 (0·05) | |||
| align="center" | 5·6 | |||
| align="center" | 2·8 | |||
| align="center" | 3–21·5 | |||
| align="center" | 0–11 | |||
| align="center" | 7 | |||
| align="center" | 2·5–16 | |||
| align="center" | 0–9·8 | |||
| align="center" | 12 | |||
| align="center" | 22 | |||
| align="center" | 47 | |||
|- | |- | ||
| | |1–3 months | ||
| align="center" | 121–179 (150) | |||
| align="center" | +31 to +114 (75) | |||
| align="center" | 2·6 | |||
| align="center" | 0·07–0·13 (0·10) | |||
| align="center" | 0·02–0·08 (0·05) | |||
| align="center" | 5·4 | |||
| align="center" | 2·7 | |||
| align="center" | 3–18·5 | |||
| align="center" | 0–12·5 | |||
| align="center" | 7·4 | |||
| align="center" | 5–21 | |||
| align="center" | 0–7·2 | |||
| align="center" | 12 | |||
| align="center" | 29 | |||
| align="center" | 53 | |||
|- | |||
| colspan="16" | | |||
<ul> | |||
<li><sup>a</sup> 2nd–98th percentile (mean)</li> | |||
<li><sup>b</sup> 2nd–98th percentile (1 mm=100 µV)</li> | |||
<li><sup>c</sup> 98th percentile (1 mm=100 µV)</li> | |||
</ul> | |||
|} | |||
==Distinguishing tachyarrhythmias in infants== | |||
{| class="wikitable" font-size="80%" width="100%" style="border:1px solid #E2ACB1;border-spacing:8px;" border="1" | |||
|+ Distinguishing tachyarrhythmias in infants<cite>schwarz1</cite> | |||
! style="width:80px" | | |||
! style="width:200px" | Sinus tachycardia | |||
! style="width:200px" | SVT | |||
! style="width:200px" | Atrial flutter | |||
! style="width:200px" | VT | |||
|- | |||
| valign="top" | '''History''' | |||
| valign="top" | Sepsis, fever, hypovolaemia, etc. | |||
| valign="top" | Usually otherwise normal | |||
| valign="top" | Most have a normal heart | |||
| valign="top" | Many with abnormal heart | |||
|- | |||
| valign="top" | '''Rate''' | |||
| valign="top" | Almost always <230 b/min | |||
| valign="top" | Most often 260–300 b/min | |||
| valign="top" | Atrial 300–500 b/min. Vent. 1:1 to 4:1 conduction | |||
| valign="top" | 200–500 b/min | |||
|- | |||
| valign="top" | '''R-R interval variation''' | |||
| valign="top" | Over several seconds may get faster and slower | |||
| valign="top" | After first 10–20 beats, extremely regular | |||
| valign="top" | May have variable block (1:1, 2:1, 3:1) giving different ventricular rates | |||
| valign="top" | Slight variation over several beats | |||
|- | |||
| valign="top" | '''P wave axis''' | |||
| valign="top" | Same as sinus almost always visible P waves | |||
| valign="top" | 60% visible P waves, P waves <em>do not</em> look like sinus P waves | |||
| valign="top" | Flutter waves (best seen in LII, LIII, aVF, V<sub>1</sub>) | |||
| valign="top" | May have sinus P waves continuing unrelated to VT (AV dissociation), retrograde P waves, or no visible P waves | |||
|- | |||
| valign="top" | '''QRS''' | |||
| valign="top" | Almost always same as slower sinus rhythm | |||
| valign="top" | After first 10–20 beats, almost always same as sinus | |||
| valign="top" | Usually same as sinus, may have occasional beats different from sinus | |||
| valign="top" | Different from sinus (<em>not</em> necessarily ‘wide’) | |||
|- | |||
| colspan="5" | | |||
<ul> | |||
<li>SVT = Supraventricular tachycardia</li> | |||
<li>VT = ventricular tachycardia</li> | |||
</ul> | |||
|} | |} | ||
Latest revision as of 21:17, 25 June 2010
A excellent description of the neonatal electrocardiogram has been made by Schwarz et al.[1][2]
Heart Axis
| Age | QRS Axis Normal Values | Abnormal Values | Description | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Adult | -30° to 90° |
|
| ||||||||||
| 8 to 16 years | 0° to 120° | >120° | Right-axis deviation | ||||||||||
| 5 to 8 years | 0° to 140° | >140°
<0° |
Right-axis deviation
Left-axis deviation | ||||||||||
| 1 year to 5 years | 5° to 100° | >100° | Right-axis deviation | ||||||||||
| 1 mo to 1 y | 10° to 120° | >120°
<10° to -90° |
Right-axis deviation
Left-axis deviation | ||||||||||
| Neonate | 30° to 90° | >190° to -90°
<30° to <-90° |
Extreme right axis deviation
Left axis deviation |
Conduction: definition of LBBB and RBBB in children
- RBBB: if consistent morphology and if QRS width >90ms in children < 4 years and >100ms in children 4-16 years[3]
- LBBB: if consistent morphology and QRS width >90ms in children < 4 years and >100ms in children 4-16 years[3]
Normal neonatal ECG standards
| Age group | Heart rate (beats . min-1) |
Frontal plane QRS axisa (degrees) |
P wave amplitude (mm) |
P-R intervala (s) |
QRS durationa V5 |
Q IIIc (mm) | QV6c (mm) | RV1b (mm) | SV1b (mm) | R/S V1c | RV6b (mm) | SV6b (mm) | R/S V6c | SV1 + RV6c (mm) | R + SV4c (mm) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 0–1 days | 93–154 (123) | +59 to +192 (135) | 2·8 | 0·08–0·16 (0·11) | 0·02–0·08 (0·05) | 5·2 | 1·7 | 5–26 | 0–22·5 | 9·8 | 0–11 | 0–9·8 | 10 | 28 | 52 |
| 1–3 days | 91–159 (123) | +64 to +197 (134) | 2·8 | 0·08–0·14 (0·11) | 0·02–0·07 (0·05) | 5·2 | 2·1 | 5–27 | 0–21 | 6 | 0–12 | 0–9·5 | 11 | 29 | 52 |
| 3–7 days | 90–166 (129) | +77 to +187 (132) | 2·9 | 0·08–0·14 (0·10) | 0·02–0·07 (0·05) | 4·8 | 2·8 | 3–24 | 0–17 | 9·7 | 0·5–12 | 0–9·8 | 10 | 25 | 48 |
| 7–30 days | 107–182 (149) | +65 to +160 (110) | 3·0 | 0·07–0·14 (0·10) | 0·02–0·08 (0·05) | 5·6 | 2·8 | 3–21·5 | 0–11 | 7 | 2·5–16 | 0–9·8 | 12 | 22 | 47 |
| 1–3 months | 121–179 (150) | +31 to +114 (75) | 2·6 | 0·07–0·13 (0·10) | 0·02–0·08 (0·05) | 5·4 | 2·7 | 3–18·5 | 0–12·5 | 7·4 | 5–21 | 0–7·2 | 12 | 29 | 53 |
| |||||||||||||||
Distinguishing tachyarrhythmias in infants
| Sinus tachycardia | SVT | Atrial flutter | VT | |
|---|---|---|---|---|
| History | Sepsis, fever, hypovolaemia, etc. | Usually otherwise normal | Most have a normal heart | Many with abnormal heart |
| Rate | Almost always <230 b/min | Most often 260–300 b/min | Atrial 300–500 b/min. Vent. 1:1 to 4:1 conduction | 200–500 b/min |
| R-R interval variation | Over several seconds may get faster and slower | After first 10–20 beats, extremely regular | May have variable block (1:1, 2:1, 3:1) giving different ventricular rates | Slight variation over several beats |
| P wave axis | Same as sinus almost always visible P waves | 60% visible P waves, P waves do not look like sinus P waves | Flutter waves (best seen in LII, LIII, aVF, V1) | May have sinus P waves continuing unrelated to VT (AV dissociation), retrograde P waves, or no visible P waves |
| QRS | Almost always same as slower sinus rhythm | After first 10–20 beats, almost always same as sinus | Usually same as sinus, may have occasional beats different from sinus | Different from sinus (not necessarily ‘wide’) |
| ||||
References
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