The essentials of pediatric ECGs, Part 1

Interpreting pediatric ECGs

Sep 1, 2007
By: Peter Morelli, MD, Thomas Biancaniello, MD, Latha Chandran, MD, MPH
Contemporary Pediatrics

Reading and interpreting pediatric ECGs

Waves, squares, tracings, line segments, grids...all set against salmon-colored paper! It
can be frustrating to deal with, but you can decipher pediatric ECGs without breaking a
sweat.
Although pediatric patients do not routinely have electrocardiograms (ECGs), there are
times for their inclusion. Symptoms of chest pain, syncope, or palpitations, first degree
relatives with significant dysrhythmia or cardiomyopathy concerns, or the initiation of
rhythm-altering behavioral medications are all suitable instances for the use of a
pediatric ECG. But as many practitioners have learned first-hand, interpreting the data
from this roll of paper can be anything but straightforwardoccasionally stirring up
copious amounts of aggravation. A firm understanding of the fundamental principles of
ECG can quell this reaction, and help guide your clinical decisions.
In general, you should analyze a pediatric ECG (or one for any age range) with respect
to the following eight parameters:
1 General quality/technique
2 Rate
3 Rhythm
4 QRS axis
5 Atrial enlargement
6 Ventricular hypertrophy
7 PR/QRS/QT intervals
8 ST segment/T wave morphology
Part 1 of this article examines the first four principles required for basic ECG
interpretation. The remaining parameters will be discussed in the October 2007 issue of
Contemporary Pediatrics.
1 General quality/technique
Accurate assessment of an ECG naturally requires proper test set-up. With that, the ECG
should have a minimum of 12 leads: six limb leads (Leads I, II, III, aVR, aVL and
aVF) and six precordial leads (V1 to V6).
All six limb leads require two electrodes in order to be properly positioned, which
results in a normal electrical vector (Figure 1a). Proper positioning of the precordial
leads begins with good chest wall orientation. Lead V1 must be positioned as the initial
reference point, and starts at the fourth intercostal space on the right side of the sternum.
V2 is placed in the same space, just left of the sternal border. All remaining leads follow
down and across the left precordium (Figure 1b). An important adaptation to pediatric

ECG technique (up to age 2) involves the placement of lead V4

to the right precordium at the anterior axillary line in the fifth
intercostal space. This is done to avoid errors in interpretation
due to the dominance of the right ventricle during this age, and
prevent direct contact between the electrodes and the precordial
leads.
One of the most common
positioning errors made is the
reversal of the right arm (RA) and left arm (LA) leads.
This would make the QRS axis appear rightward when
one would expect it to be left in a normal individual. If
the limb leads are placed properly, however, lead I
should appear very similar to precordial lead V6. This is Figure 2
an easy way to detect limb lead reversal (Figures 2-3).
Figure 1

Along with proper lead positioning is the determination

of axis. The axis is the summation of all electrical
vectors created by the atria (p axis) or the ventricles
(QRS axis). Figure 4 demonstrates a simple way to
determine the axis of a wave. For example, to determine
the axis of the p wave, one would look at the polarity of
Figure 3
the p wave in Lead I and in aVF. If the p wave is
positive in both of these leads, then the p axis is normal. In most children, both the p
axis and the QRS axis should be in the "normal" quadrant.
Two other crucial set-up items are paper speed and voltage
standards. All ECG paper speed should be set at a rate of 25
mm/sec. If the paper speed is faster, all the intervals will appear
prolonged, and the heart rate appears slow. All voltage standards
should be set at 10 mm/millivolt. Half standard voltages (5
mm/millivolt) will create the appearance of normal voltage in the
presence of excess atrial or ventricular voltage, thereby missing
Figure 4
chamber enlargement.

Figure 5

After assuring the ECG was performed correctly, the

interpretation can then follow. This begins with an
assessment of the six basic waves on an ECG: the p wave
(atrial contraction), the QRS complex (ventricular
depolarization), and the ST segment and T wave
(ventricular repolarization). Figure 5 shows a normal ECG
rhythm composed of each of these waves. In the following
paragraphs we discuss each component of the ECG
systematicallythe normal findings and the most common
abnormalities seen.

2 Rate
Heart rate can be interpreted by one of two methods. In
a routine 12-lead ECG, the tracing that is generated on
8.5" 2 11" paper occurs over 10 seconds. One simple
way to obtain the heart rate is to count the number of
QRS complexes in that 10-second time period, and
multiply by six, to arrive at the heart rate per minute.
Figure 6
(Figure 6)
Another popular method takes advantage of the dark lines spaced 5 mm apart. A QRS
complex on two successive dark lines implies a heart rate of 300 beats per minute
(bpm). QRS complexes that are two dark lines apart equal a heart rate of 150 bpm.
Complexes that are three dark lines apart equal 100 bpm; four lines apart, 75 bpm; six
lines apart, 50 bpm. Thus one simply divides the number 300 by the number of dark
lines separating the QRS beats to arrive at the actual heart rate.
3 Rhythm
A very important component of pediatric ECG analysis
lies in identifying the mechanism of the rhythm. The
rhythm should be normal sinus in most individuals. This
implies that the p wave axis is 0 to 90 degrees (Figure
Figure 7
4). However, some individuals may have an ectopic
atrial rhythm, which is denoted by a p wave axis outside of this quadrant. Among
pediatric patients, this finding may be indicative of atrial situs inversus, resulting in a p
wave axis of 90 to 180 degrees. If you are confronted with a narrow QRS rhythm absent
of a p wave, this is likely to be a junctional rhythm. A wide QRS rhythm without a p
wave is likely to be a ventricular escape rhythm.

Figure 8

The next aspect of rhythm

interpretation involves the
regularity of the pattern. An
irregular rhythm is most
commonly due to respiratory
variation, resulting in sinus
arrhythmia (Figure 7). There
Figure 10

Figure 9

may also be premature atrial contractions (PACs) (Figure 8); junctional or ventricular
beats that result in noncompensatory or compensatory pauses causing an irregular heart
rate. A rapid, wide QRS tachycardia can be caused by either ventricular tachycardia or a
supraventricular tachycardia with aberrant conduction, the former being more common.
Figure 9 demonstrates ventricular tachycardia. Note the QRS polarity being opposite
that of the T wave's polaritythis is a red flag for ventricular tachycardia. One of the
most important pitfalls in evaluating rhythm is not recognizing the presence of motion
artifacts, such as hiccups or muscle twitches, and misperceiving them as ectopic beats
(Figure 10).
4 QRS axis
The QRS axis in children may reveal underlying congenital heart disease. In the
newborn period, the QRS axis may normally be significantly rightward upwards of 165
degrees (Figure 4). By 4 weeks of age, the axis quickly shifts leftward to a maximum of
115 degrees. This coincides with the change in ventricular predominance from a right
ventricular fetal mode to a mature left ventricular mode.

Figure 11

The presence of a left superior axis (Figure 11) is often

indicative of either an endocardial cushion defect (aka
atrioventricular canal defect) or tricuspid atresia. A
quick clinical pearl lies in the premise that if a child is
cyanotic with such an abnormal axis, the likely
diagnosis is tricuspid atresia. If the child is pink and
well oxygenated, the most probable diagnosis is an
atrioventricular canal defect.

ECG Challenge: What's your diagnosis?

Now 5-6-7-8

ECG Challenge:
What's your
diagnosis?

In Part 2 of this article, we will discuss how to recognize chamber

enlargement and measure key intervals in an ECG (items 58 ). We
will also provide answers to the challenge studies presented in this article.

Editor's Note: Look for "The essentials of pediatric ECGs: Part 2-The last four
fundamentals" in the October issue of Contemporary Pediatrics.