Pediatric EKG Interpretation

The first thing providers should know about Pediatric EKG Interpretation is that a normal pediatric EKG looks, in many cases, entirely different than that of an adult.  In this episode of the podcast, we will discuss some of the basics of Pediatric EKG Interpretation.

Show Notes

When Do I Need a 12-Lead for a Pediatric Patient?

There are many reasons why a 12-Lead EKG should be obtained for a pediatric patient in the field.  A brief (but not all-inclusive) list of these times includes:

• Known cardiac history
• Family history of sudden cardiac arrest
• Syncope
• Seizures
• Chest pain following exertion
• Toxic Exposures
• Cyanotic episodes
• Dysrhythmias

As with any patient, if you have any indication that their symptoms could be of cardiac origin, get the 12-Lead!

What Anatomic Differences Should I Consider?

• Children are born with dominant right ventricles
• Pediatric patients may have thinner chest walls
• Pediatric patients have smaller hearts than adult patients

What is Different About the EKG in a Pediatric Patient?

• Rate (Increased due to lower stroke volume)
• Rhythm
  • Sinus arrhythmia is more pronounced in younger children
  • Sinus rhythm
    • Consistent PR Interval
    • Positive P-wave deflection in II &aVF, negative in aVR
• Intervals
  • Typically shorter due to smaller myocardial size
  • See chart below

• Voltage
  • May be enormously exaggerated due to thinner chest wall
• T Waves
  • Juvenile T Wave Inversion pattern
    • T wave inversion in leads V1-V3
    • Usually present from 7 days of age – adolescence
    • May persist into adulthood (rare)
• Identifying Left & Right Ventricular Hypertrophy
  • Due to voltage differences, cannot be assessed the same way as adults
  • Identifying LVH & RVH via EKG is not entirely accurate, but should raise your suspicion
  • Left Ventricular Hypertrophy
    • Use lead V6 only 
    • R wave that intersects the isoelectric line of V5
  • Right Ventricular Hypertrophy
    • Use lead V1 only
    • Upright T waves after ~ 7 days old
    • RSR’ pattern with R’>R
    • Pure R wave after ~ 6 mos. old

How to Master Pediatric EKG Interpretation

• Read everything you can.   Check out the references at the bottom of the show notes for some excellent resources.
• Interpret as many pediatric EKG’s as you can, the more normal ones you look at, the more abnormal an abnormal one will appear to you.
• Teach others what you know!  Many times, you learn a topic much better when you explain it to someone else.

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Owen Wood

References

Altman D. Introduction to pediatric ECG. EMS1. 2017 Apr 17 [accessed 2017 Nov 3]. https://www.ems1.com/ems-products/cpr-resuscitation/articles/230602048-Introduction-to-pediatric-ECG/

Burns, E. Paediatric ECG Interpretation – Life in the Fast Lane Medical Blog. LITFL • Life in the Fast Lane Medical Blog. 2017 Apr 10 [accessed 2017 Nov 3]. https://lifeinthefastlane.com/ecg-library/paediatric-ecg-interpretation/

Dickinson DF. The normal ECG in childhood and adolescence. Heart. 2005 Dec [accessed 2017 Nov 3]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1769212/

Evans WN, Acherman RJ, Mayman GA, Rollins RC, Kip KT. Simplified Pediatric Electrocardiogram Interpretation. Clinical Pediatrics. 2010;49(4):363–372.

Rijnbeek P. New normal limits for the paediatric electrocardiogram. European Heart Journal. 2001;22(8):702–711.