ECG READING

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ECG READING ; Pediatric Cardiology

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Presentation Transcript

Slide 1: 

Thiruvananthapuram G r e e t i n g s F r o m

Demystifying Pediatric CardiologyE C G R E A D I N G How To Make Sense Of The Black Squiggles : 

Demystifying Pediatric CardiologyE C G R E A D I N G How To Make Sense Of The Black Squiggles M. Zulfikar Ahamed Professor of Pediatric Cardiology Medical College Trivandrum

The Machine & The Man : 

The Machine & The Man

ECG Machine : 

ECG Machine

ECG INTERPRETATION : 

ECG INTERPRETATION CHD Acq HD Arrhythmias In adult In The Young

TODAY’S PLAN 7 point formula : 

TODAY’S PLAN 7 point formula 1. Introducing the Basics of reading an ECG 2. ECG Reading format 3. Abnormalities 4. Frequently Encountered Issues & Problems 5. Clinical Scenario with ECG 6. FAQ 7. Conclusion demo ECG

Slide 8: 

ECG Basic concepts - Recording Recording in heat sensitive paper Page writer using ink

Slide 9: 

Single channel / Multi channel Paper speed : 25 mm / sec 1 small div = 40 msec Voltage : 1 mv = 10 mm 1 small div = 0.1 mv TAKING A NORMAL ECG

Slide 10: 

ECG PAPER

Slide 11: 

BASICS Paper speed : 25 mm/ sec Double speed : 50 mm/ sec Standardization : 1 mV = 10 mm Half / Double Over damped tracing Under damped tracing

Different Types of Leads : 

Different Types of Leads Standard Limb Leads I, II & III Augmented Unipolar Limb Leads aVR aVL aVF Unipolar Chest Leads V1 V2 & V3 Unipolar Chest Leads V4V5 & V6

Slide 13: 

ECG - Basic concepts Bipolar Limb Leads / Standard Limb Leads Unipolar Limb Leads Unipolar Chest Leads 14 LEAD ECG Why ? V3R to V6R in Dextrocardia V3R and V4R in TOF and Cong HD V3R and V4R in RVMI, RVH

Slide 14: 

Rhythm Analysis Rhythm strip or Long lead Lead II and V1

Slide 15: 

STANDARDIZATION

Slide 16: 

READING A NORMAL ECG

Slide 17: 

ECG Reading Format Paper speed Standardization Rhythm & Heart Rate P wave PR interval QRS Width / Axis / Morphology R / S in V 1 : V 6 ST segment T wave QTc U wave

Slide 18: 

Normal Sinus Rhythm Normal P wave – Upright in lead I, II and inverted in aVR Normal morphology Each P to be followed by a QRS with a normal PR interval - Normal PQRST Fairly regular PP interval

Slide 19: 

Heart Rate Usual paper speed : 25 mm / sec Distance moved by the paper in one minute / 60 seconds = 25 X 60= 1500 mms Heart rate = 1500 / R-R interval Average of multiple beats in AF

Slide 20: 

CALCULATING THE HEART RATE 1500 RR interval in no. of small divisions

Slide 21: 

HEART RATE Tachycardia newborn > 160 / mt infant > 120 / mt child / adult > 100 / mt Bradycardia newborn < 90 / mt infant < 80 / mt child / adult < 60 / mt

Slide 22: 

ECG - Waves P : Atrial depolarization QRS : Ventricular depolarization T : Ventricular repolarization “Ta wave” : Atrial repolarization U wave

Slide 23: 

ECG - Intervals PR interval QT interval

Slide 24: 

ECG - Segments PR segment ST segment TP segment

Slide 25: 

P wave Look at II V1 Width . Height . Morphology. Polarity. Absent ?

Slide 26: 

P wave Normal Upright in Lead I, II and inverted in avR Leads II and V1 Height: < 2.5 mm in Lead II < 1.5 mms in Lead V1 Width: < 110msec in Lead II in adults < 100 msec in child

Slide 27: 

PR interval Beginning of atrial depolarization to beginning of ventricular depolarization. Measured from beginning of P wave to beginning of QRS Normal in adults: 120 – 200 msecs Short PR interval and Prolonged PR interval

Slide 28: 

200 ms MEASURING PR INTERVAL

Slide 29: 

PR INTERVAL Short PR : < 80 msec Long PR : > 180 msec > 200 msec New born : PR interval - > 145 msec Infants and children - > 180 msec

Slide 30: 

PR segment Measured from end of P wave to beginning of QRS Normally iso electric PR segment depression in pericarditis

QRS Interpretation : 

QRS Interpretation Axis Width . Voltage q wave if any R / S in V1 and V6 Transition Abnormal morphology eg: RBBB etc

Slide 32: 

QRS axis Normal RAD LAD Right Upper Quadrant Axis

Slide 33: 

QRS Complex - Axis Determination Normal : 0 0 to + 90 0 RAD : +90 0 to + 180 0 LAD : 0 0 to - 90 0 RUQ : - 90 0 to + 180 0

Slide 34: 

Quick Determination of Axis If I & aVF are Positive If I Neg aVF Positive If I Positive aVF Negative If I & aVF are Negative Normal RAD LAD RUQ

Slide 35: 

Normal QRS Axis in children At birth : + 60 to +190 degrees 1 – 3 months : + 30 to + 115 degrees

Slide 36: 

QRS Axis in adults Normal: - 30 degrees - + 110 degrees RAD : Beyond + 110 degrees LAD : Beyond – 30 degrees

Slide 37: 

Abnormal axis in children : RAD - > 120° LAD - < 0 °

Slide 38: 

DETERMINATION OF AXIS - EXERCISE

Slide 42: 

QRS DURATION

Slide 43: 

QRS duration Narrow QRS Wide QRS in children - > 100 msec Wide QRS in adult : - > 110 msec

Slide 44: 

Wide QRS Ventricular complex Pre excitation ( WPW) Bundle branch block Intraventricular conduction abnormalities Electrolytes / Drugs “Aberrancy” with fast heart rates

Slide 45: 

Normal QRS in V1 Varies with the age R / s in infants & young children - > 1 r / S in adults with r / S ratio < 1

Slide 46: 

ECG – 5 DAY OLD INFANT

Slide 47: 

8 month old infant

Slide 48: 

6 year old child

Slide 49: 

22 year old adult

Slide 50: 

R in V1 and V6 in children R wave usually prominent in right precordial leads R wave in V1 up to 20 or 25 mms can be normal in term newborn R wave in V1 rapidly decreases in the first week of life and R in V6 becomes prominent R / s in V6 in infants & children almost always > 1

TRANSITION OF QRS precordial leads : 

TRANSITION OF QRS precordial leads Normal : At V3 V4 Early : At V2 V1 Late : At V5 V6

ST - Segment : 

ST - Segment Normal Depressed Elevated Normal ? Abnormal ?

ST Segment Elevation : 

ST Segment Elevation

ST segment Depression : 

ST segment Depression

T wave : 

T wave a . T wave polarity < 3 - 4 days - T is upright in V1. V3R > 3 - 4 days - 12 years - T inverted in V1 V3 R V2 (V3) b. T wave Height Shape Crucial

T wave : 

T wave

Slide 58: 

T wave in V1 Almost always upright in term new born infants Becomes inverted by 4 -7 days of life Negative T waves persist up to 8 years and sometimes longer. “Persistent juvenile T wave pattern” Upright T in V1 between 7 days to 7 years may signify RVH.

Slide 59: 

QT interval Measured from beginning of QRS to end of T wave. Usually Lead II in single channel recorder / Precordial lead Earliest onset of QRS in any lead to end of T wave in any lead in a multi channel recorder Bazett formula for corrected QT interval QT in msec / sq root of RR in secs

Slide 60: 

MEASURING QT INTERVAL – QT PROLONGATION

Slide 61: 

QT interval Normal : < 0.44 sec Borderline : 0.44 to 0.46 sec Abnormal : > 0.46 sec Congenital QT prolongation – LQTS Drugs

Slide 62: 

QTc prolongation LQTS Hypokalemia Hypocalcemia Hypothermia Anti arrhythmic drugs I A or III Ischemia

Slide 63: 

Chamber Enlargement Atrial Overload / Enlargement LAO / RAO / BAO Ventricular Hypertrophy LVH / RVH / BVH Systolic and Diastolic overload pattern

CHAMBER ENLARGEMENT : 

CHAMBER ENLARGEMENT LV Pressure Volume Pressure Volume RV RA. LA

Slide 65: 

RA overload

Slide 66: 

Left Atrial overload

Slide 67: 

Bi atrial overload

Slide 69: 

RVH Systolic overload pattern Diastolic overload pattern

Slide 70: 

RV SYSTOLIC OVERLOAD Type A

Slide 71: 

RVH Type B

Slide 72: 

Ecg #302 RVH Type C

Slide 73: 

Left Ventricular Hypertrophy

LV VOLUME OVERLOAD : 

LV VOLUME OVERLOAD

Slide 75: 

Biventricular hypertrophy Katz – Wachtel phenomenon R + S in mid precordial leads Infant > 60mm Child / Adult > 45 mm

Slide 76: 

Biventricular hypertrophy

Slide 77: 

Ectopic beats Premature Escape beat Supraventricular / Ventricular

Slide 78: 

Supraventricular ectopic

Slide 80: 

Ventricular Ectopic

Slide 82: 

Sinus tachycardia

Slide 83: 

Sinus Bradycardia

Sinus Node Dysfunction : 

Sinus Node Dysfunction Sinus bradycardia Sinus arrest SA block Brady-tachy syndrome Chronotropic incompetence

Slide 85: 

SA block First, Second and Third degree Only second degree can be diagnosed from ECG Type I and Type II second degree

Slide 86: 

Second degree SA block

Slide 87: 

AV block First degree Second degree – Type I and II Third degree ( Complete)

Slide 88: 

First degree AV block 340 MS

Slide 89: 

Wenckebach phenomenon Mobitz I

Slide 90: 

Mobitz II

Slide 91: 

Complete AV heart block Regular PP interval Regular RR interval Varying PR interval AV Dissociation

Slide 93: 

LBBB

Slide 94: 

RBBB

Slide 95: 

Tachy arrhythmias Narrow QRS Wide QRS

Slide 96: 

TACHYCARDIA VT A. Narrow QRS (< 120 msec) B. Wide QRS (>120 msec) SVT with RBBB Aberrancy Drugs Pre excited Tachycardia QRS width

Slide 97: 

A. Narrow QRS tachycardia Irregular Atrial fibrillation Multi focal atrial tachycardia Regular Automatic Atrial Reentry AVNRT } SVT AVRT

Slide 98: 

SVT

Slide 100: 

SVT

Slide 101: 

WPW Syndrome PR interval < 120 msec with normal P Wide QRS > 110 msec Initial slurring of QRS – delta wave Secondary ST – T changes

Slide 102: 

Pre excitation

NS VT : 

NS VT

VT : 

VT

VT : 

VT

Slide 106: 

Tachycardiomyopathy Dilated LV with global reduction in contractility related to very fast heart rate Clinical picture simulates dilated Cardiomyopathy or myocarditis Immediate termination of arrhythmia required

Slide 107: 

Atrial fibrillation Absence of P waves Varying RR interval Fibrillary waves

Slide 108: 

ATRIAL FIBRILLATION

Slide 109: 

ATRIAL FLUTTER

Slide 110: 

PACEMAKER

Slide 111: 

ECG Reading Format - “ Rule of 10” 1. Rate 2. Sinus or not 3. P wave 4. PR interval 5. QRS Axis 6. QRS R/S Addl observation if any 7. ST segment 8. T wave 9. QTC 10. Other remarks In V1 in V6

Slide 112: 

CONGENITAL HEART DISEASE ECG

Slide 113: 

P waves in CHD Looked at not only for chamber enlargement - RA or LA or biatrial but for SITUS Situs solitus - Upright P in I ; Negative in aVR Situs inversus - Negative P in I ; Upright in aVR

PR Interval in CHD : 

PR Interval in CHD IF long : Strongly s/o Rheumatic etiology : Digitoxicity : Some interesting CHD Familial secundum ASD AV Canal Defect ( including primum ASD) DORV . L - TGA. Ebstein.

Slide 115: 

QRS Voltages In deciding high/ low always apply voltage criteria ( modified Sokolow criteria) Children tend to have high voltage precordial QRS In infants and children myocarditis and DCM need not produce low voltage complexes

Slide 116: 

Q in QRS To decide whether Q is Abnormal Apply definite criteria Deep q in II. III. aVF are occasionally found in normal infants Deep q in a specific coronary artery territory is suspicious II. III. aVF I. aVL, V4 -V6 V1 -V6

Slide 117: 

Deep Q found in 1. LV volume over load situation II. III. aVF, V4 -V6 2. Infarction pattern ALCAPA Kawasaki Myocarditis

Slide 118: 

qR in VI Can not be Normally Present ! If qR in V1 or V3 R Suprasystemic RVSP ( severe PAH or PS ) Ventricular inversion - L-TGA EMF - giant RA No q in V5 V6 - ? SINGLE VENTRICLE

Slide 120: 

TRANSITION OF QRS precordial leads Normal : At V3 V4 Early : At V2 V1 Late : At V5 V6

Slide 122: 

R/S relationship in precordial leads Progressive decline of R in V1 to V6 ? Dextrocardia r / S in all precordial leads ? Cor pulmonale RVH adult ? Single Ventricle infant

Slide 123: 

QRS Axis In infants RAD is normal ; Most Abnormal heart in infancy will also have RAD ! * if > + 1350 - likely abnormal Unusual Axis - LAD , RUQ are most useful in diagnosis

Slide 124: 

LAD in CHD 1. AVCD - including primum ASD 2. Tricuspid Atresia 3. Inlet or multiple muscular VSD 4. L - TGA 5. Single ventricle

A Funny looking baby presents with CHF , mild Cyanosis . Has cardiomegaly, PAH, PSM and MDM . : 

A Funny looking baby presents with CHF , mild Cyanosis . Has cardiomegaly, PAH, PSM and MDM .

Slide 132: 

A 12 Year old with H / O fever, cough and severe dyspnea. IN HYPOTENSION.

Slide 133: 

Ecg #313

Slide 134: 

Sinus rhythm Narrow, tachy @110 Normal axis/int’s The QRS complex morphology is variable… Dx: Electrical alternans Due to the heart swinging freely inside a large pericardial effusion

A 4 Month old baby with CHF, Cardiomegaly, apical murmur with h /o Episodes of extreme irritability : 

A 4 Month old baby with CHF, Cardiomegaly, apical murmur with h /o Episodes of extreme irritability

TACHYCARDIA ? : 

TACHYCARDIA ? Ecg #303

Slide 139: 

Wide complex tachycardia DDx: V T or SVT with aberrancy… 80% of wide complex tach’s are VT; hence this is VT until proven otherwise

Palpitations, DOE , Syncope : 

Palpitations, DOE , Syncope Ecg #307A

Slide 141: 

Extremely fast rhythm (240bpm, must be Supraventricular, VT rarely this fast) Irregular! (VT & torsades are always regular) All QRS complexes have initial upsloping Dx: Afib & pre-excitation Wide complex tachycardia

Same patient… after DC CV : 

Same patient… after DC CV Ecg #307B

A Child of 10 years Abnormal facies, short stature andEjection Systolic Murmur at PA : 

A Child of 10 years Abnormal facies, short stature andEjection Systolic Murmur at PA

Slide 145: 

Infant CHF Acyanotic Normal Femorals murmur Diagnosis : VSD - large ECG : RAD . Katz Wachtel phenomenon

Slide 146: 

CASES & ECG Infant ‘ Asymptomatic VSD’ ECG: RAD . RVH - TOF ? LAD . BVH - AVSD ?

Suspected to have CHD in Newborn period. LFU. Now 12 YRS, has DOE, Mild cyanosis : 

Suspected to have CHD in Newborn period. LFU. Now 12 YRS, has DOE, Mild cyanosis

Slide 151: 

CASES & ECG Asymptomatic Child Hyperkinetic Precordium Insignificant M at Lt USB wide split S2 ? ASD ECG: RAD r S R in V1 or V3 R

Slide 154: 

CASES & ECG Asymptomatic ; long m Lt USB EJ click + ? PS ECG : Monophasic R in V1 V3 R RAD. No early transition Good correlation with severity

Slide 158: 

CASES & ECG 4 month old symptomatic CoA ECG : will show RVH - not LVH if LVH - additional abnormalities PDA - VSD mitral Anomalies

Slide 160: 

CASES & ECG TOF like clinical picture RAD RVH Early transition ( peaked p wave + )

Slide 164: 

V1 l - TGA

Slide 165: 

TOF like Picture LAD Tricuspid Atresia AVCD PS L- TGA PS TOF like 1 AV block DORV VSD PS AVCD VSD PS TOF like no q in V5 V6 L- TGA

Slide 166: 

Neonate Deep Cyanosis . Mild CHF Think of D TGA

Slide 169: 

Cyanotic new born with RDS If ECG shows RVH + strain Think of PPHN TAPVC CoA

Slide 170: 

17 yr old girl . Previous VSD LFU Now clinically PAH . Operable ? ECG: RVH . PA pressure ?

Slide 173: 

Asymptomatic boy 8 yrs murmur ECG: T inverted in V1 - V6 Think of primary myocardial diseases HCM DCM

13 Year old GirlH / O frequent Palpitations : 

13 Year old GirlH / O frequent Palpitations

PR interval if SHORT : 

PR interval if SHORT Think of WPW look at Other causes ( Pompe ; LGL etc ) are rare ! QRS

A 14 Yr old Boy. History of Syncope.Basal harsh ESM. ? Cause : 

A 14 Yr old Boy. History of Syncope.Basal harsh ESM. ? Cause

Bradycardia ? Cause : 

Bradycardia ? Cause

TACHYCARDIASinus or SVT ? : 

TACHYCARDIASinus or SVT ?

The next - Tachycardia ? Wide or Narrow : 

The next - Tachycardia ? Wide or Narrow

Newborn in CHF & in Shock.Why ? : 

Newborn in CHF & in Shock.Why ?

A 6 Yr old boy referred as BRADYCARDIA . History of ‘ Syncope’ ? Cause : 

A 6 Yr old boy referred as BRADYCARDIA . History of ‘ Syncope’ ? Cause

Slide 190: 

ECG 2

Slide 191: 

FAQ I . Why should we take an addl. V3R in infants and children ? Up to What Age ? II. In Dextrocardia which are the addl. Leads to be taken ? III. Right Axis Deviation is normal in infancy. Up to what Age it remains normal ?

Slide 192: 

FAQ IV . Can you normally get T inversion in V4 - V6 in children as a variation ? V . What is Juvenile pattern of ECG ? VI. VPC in child. When will we order a detailed investigation ?

Slide 193: 

FAQ VII. Sometimes we get rSR pattern in limb leads Is it significant ? VIII. Q R in V1 is generally indicative of severe PAH - suprasystemic . Does it hold good for V3R, V4R also? IX. Which are the clinical conditions in which we expect WPW ?

Slide 194: 

FAQ X. Indications of ECG in chest pain syndrome in children ? XI. What are the early ECG findings in Digoxin toxicity ? XII. T inversion in precordial leads; what is normal and what is abnormal ?

Slide 195: 

FAQ XIII. QRS duration in children vs adults . Is there a major change ? XIV. When is ST elevation significant in children ? XV. rSR m ASD ; Is it useful for follow up ?

Slide 196: 

FAQ XVI. In which CHD , follow up can be done utilizing ECG alone, instead of Echo ? XVII. In a child with bradycardia, how is a diagnosis reached ? XVIII. What are early repolarisation changes in ECG ?

Slide 197: 

Thank you very much ! Usha. Maharashtra IAP. All my fellow Pediatricians