Selected topic: Cardiology commentary
Electrocardiographic Manifestations: Pediatric ECG

https://doi.org/10.1016/j.jemermed.2007.09.039Get rights and content

Abstract

Interpretation of pediatric electrocardiograms (ECGs) can be challenging for the Emergency Physician. Part of this difficulty arises from the fact that the normal ECG findings, including rate, rhythm, axis, intervals and morphology, change from the neonatal period through infancy, childhood, and adolescence. These changes occur as a result of the maturation of the myocardium and cardiovascular system with age. Along with these changes, up to 20% of pediatric ECGs obtained in the acute setting may have clinically significant abnormal findings. This article will discuss the approach to the interpretation of ECGs in children, the age-related findings and alterations on the normal pediatric ECG, and those ECG abnormalities associated with pediatric cardiac diseases, including the variety of congenital heart diseases seen in children.

Introduction

Interpretation of pediatric electrocardiograms (ECGs) can be challenging in the Emergency Department (ED) setting. ECGs are obtained in children in the ED for a variety of reasons. Up to 20% of these have clinically significant findings such as prolonged QT syndrome, ventricular hypertrophy, or ectopy (1). Part of the challenge of pediatric ECGs is the fact that typically “abnormal” electrocardiographic findings in adults may, in fact, be normal or expected findings in children, depending on the age of the patient. These differences are the result of the changes and development of the myocardium and circulatory system from infancy through childhood to adulthood.

This article will review the ECG manifestations of the normal and common clinical conditions of pediatric patients presenting to the ED. In general, we suggest the use of a systematic approach to ECG interpretation, with special attention to rate, rhythm, axis, ventricular and atrial hypertrophy, and repolarization abnormalities. This approach will assist the clinician in determining what is normal on the pediatric ECG and what may be indicative of an abnormal cardiac condition.

Section snippets

Case 1

A 3-year-old girl was brought in to the ED by her parents due to 3 days of poor feeding, vomiting, and diarrhea. On examination, the patient appeared to be a well-developed, fussy toddler with no significant physical findings other than a 2/6 systolic murmur radiating to the base. Due to the finding of the murmur, the Emergency Physician obtained an ECG (Figure 1). The ECG was notable for sinus tachycardia at a rate of 112 beats/min and inverted T waves in leads V1, V2, and V3. These findings

Approach to the Pediatric ECG

Electrocardiograms are obtained on children for a variety of reasons. The most common indications include the evaluation of chest pain, workup for possible dysrhythmia, evaluation of an acute episode (i.e., syncope), or toxicology workup after ingestion. In a review of over 1600 ECGs obtained at a pediatric ED, the most common indications were chest pain (21%), seizure or syncope evaluation (18%), dysrhythmia evaluation (17%), respiratory event or apparent life-threatening event (16%),

Age-Related Pediatric ECG Findings

Rapid changes occur over the first year of life as a result of the dramatic evolution in circulation and cardiac physiology. After infancy, subsequent changes are more gradual until late adolescence and adulthood. In the fetus, blood is shunted away from the lungs by the patent ductus arteriosus (PDA), and systemic circulation relies primarily on the right side of the heart. As a result, at birth the right ventricle is larger than the left ventricle. Subsequently, as the PDA closes during

Tachydysrhythmias

Tachydysrhythmias are common in pediatric patients seen in the ED. The normal range for heart rate decreases with age and an increased rate can be normal, particularly in young children (Table 1). In addition, because cardiac output is more dependent on heart rate than stroke volume in children, a fast heart rate can be a normal physiologic response to stressors such as fever, dehydration, and pain, which are often related to the patient's reason for presenting to the ED.

Conclusion

In an ED it is necessary to quickly determine which pediatric ECG findings are normal, which are abnormal, and which must be addressed immediately. An understanding of the pediatric ECG is essential so that subtle abnormalities are not missed. Knowledge of the basics of pediatric ECG interpretation, including familiarity with the age-related normal findings in terms of heart rate, intervals, axis and waveform morphologies, is critical. In addition, clinicians should have an understanding of the

Acknowledgment

The authors thank Richard Harrigan, md, for his assistance with the manuscript.

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