Clay Dobronyi

FinancialDisclosures

PediatricECG

STATMedicalTraining

ASimpleApproach
by
ClayDobronyiBSN,RN,CCRN

AtrainingcompanythatteachesECGandAHA
certificationcourses

PediatricECG
Objectives
A&PReview
Systematic
Approachto
ReadingECGs
NormalRhythms
FastRhythms
SlowRhythms
LethalRhythms

Owner

PediatricECG
A&PReview
SANode
AVNode
BundleofHis
R&LBundle
Branches
PurkinjeFibers

PediatricECG
A&PReview

PediatricECG
A&PReview

IntrinsicHeartRates
Newbornto3years:
SAnode
AVnode(junctional)
Purkinje(ventricular)
P ki j (
i l )

95 120
45 85
35 55
35

3yearstoteenager
SAnode
AVnode(junctional)
Purkinje(ventricular)

55 120
35 65
25 45

PediatricECG
A&PReview

PediatricECG

SystematicApproach

Whatdoallthoseboxesmean?

Rhythm
Isitregular?

Rate
Fastorslow?
F
l ?

Pwaves
Present?
Whoismarriedtowhom?

Intervals PR&QRS
Allincreaseasthepatientages

PediatricECG

PediatricECG

SystematicApproach

SystematicApproach

Regularity

PrematureBeats

Irregularitycanbe
Normal
PrematureBeats
Premature Beats
DroppedBeats

PrematureAtrialContraction
PrematureVentricularContraction

Causes??

PediatricECG

PediatricECG

SystematicApproach

SystematicApproach
RateDetermination
Number of
large squares
` CountthenumberofR between two R
waves
p
wavesina6SecondStrip
1
andMultiplyby10
2
` OR
3

Subsequent
rate per
minute

Howdoourmonitorsdeterminerate?
300, 150, 100, 75

300
150
100

75

60

50

Multiplewaystodeterminerate
Findtheonethatworksforyouanduseit!

PediatricECG

PediatricECG

SystematicApproach

SystematicApproach

PWaves

Pwaves

PresentorNot?
IftherearenoPwaves;cantherhythmbesinus?

IftherearePwavesthatarenotmarried,consider
aformofheartblock.

PediatricECG

PediatricECG

SystematicApproach

SystematicApproach

Intervals PR&QRS
` Almostimpossible
tomemorize
normalvalues,
l l
becausethey
changewithage.
` Hinttoremember!
LongerthannormalPR&
QRSintervalscanmeana
slowinginconduction.

PediatricECG

SystematicApproach

IsthereaPWaveforeveryQRS?

LetsRecap!
Rhythm
Rate
Pwaves
DetermineyourIntervals
PR&QRS

MAXIMUM PR/QRS INTERVALS

AGE

HR

PRInterval

QRS

Neonate

100 180

0.11

0.03 0.08

2 12 Months
212Months

110 180
110
180

0 11 0.14
0.11
0 14

0 03 0.08
0.03
0 08

13Years

100 180

0.12 0.16

0.03 0.08

45Years

60 150

0.13 0.18

0.04 0.09

613Years

50 130

0.16 0.18

0.04 0.10

5090

0.16 0.20

0.04 0.10

14 Up

NormalRhythms
NormalSinusRhythm

` Regularity:Regular
` Rate:60100beatsperminute
` PWave:Normalandupright;oneP
waveinfrontofeveryQRScomplex
` PRI:.12.20secondsandconstant
` QRS:Lessthan.12seconds

NormalRhythms
SinusArrhythmia

NormalRhythms
SinusTachycardia

` Regularity:Irregular
` Rate:60100beatsperminute(usually)
` PWave:Normalandupright;onePwaveinfrontofeveryQRS
complex
` PRI:.12.20secondsandconstant
` QRS:Lessthan.12seconds

` Regularity:Regular
` Rate:Greaterthan100beatsperminute(usually
100160beatsperminute)
` PWave:Normalandupright;onePwaveinfront
ofeveryQRScomplex
` PRI:.12.20secondsandconstant
` QRS:Lessthan.12seconds

FastRhythmsNarrowComplex

FastRhythms

SVT

AnalyzingtheRhythm
Needa12lead
LookattheQRS
WideorNarrow?
Whatkindofsurgeryhasthe
patienthad?
Maynotbepathological.

Enhanced automaticity

Regularity:Regular
Rate:150250beatsperminute
PWave:AtrialPwave;differsfromsinusPwave;canbelostinprecedingT
wave
PRI:.12.20seconds
QRS:Lessthan.12seconds

Reentry Intra-atrial

SVTConversionPostAdenosine
15%

5%

Reentry, AV Node

5%

Reentry, AP

75%

FastRhythms
NumberoneTachycardia
seeninchildrenis?
Rememberto
look at your patient
lookatyourpatient

SlowRhythms
AnalyzingtheRhythm
Thinkaboutcauses.
Whatarethosecrazyp
What are those crazy pwaves
waves
doing?
Sinusrhythmorheartblock?
Astheconductionsystem
fails

Acalmorlethargicpatient
inafastrhythmismuch
scarierthananangry
patient.

SlowRhythms
Causes
` Namethetopcauseofan
infantsheartratedrop?

SlowRhythms
Isitsinusora
heartblock?

Sinus Bradycardia

Lookatthep
waves

Treat
Treatthepatient,don
the patient donttworryabout
worry about
therhythm.

` MedicalCauses

Treatment?

Meds

Complete
Heart Block

` SurgicalCauses
` CongenitalCauses

SlowRhythms
JunctionalEscapeRhythm

SlowRhythmsHeartBlocks
ThirdDegreeHeartBlock
` Regularity:Regular
` Rate:4060beatsperminuteif
focusisjunctional
2040beatsperminuteiffocus
isventricular
` PWave:Uprightanduniform;
P Wave: Upright and uniform;
morePwavesthanQRS
complexes
` PRI:NorelationshipbetweenP
wavesandQRScomplexes;P
wavesoccasionally
superimposedonQRS
complexes
` QRS:Lessthan.12secondsif
focusisjunctional;.12seconds
ormoreiffocusisventricular

`
`
`
`

Regularity:Regular
Rate:4060beatsperminute
PWave:Willbeinverted;canfallbefore,during,orafterQRScomplex
PRI:CanbemeasuredonlyifPwaveprecedesQRScomplex;ifmeasurable,
willbelessthan.12seconds
` QRS:Lessthan.12seconds

SlowRhythms
IdioventricularRhythm

LethalRhythms
CardiacArrestRhythms

Regularity:Usuallyregular(itcanbeunreliablesinceitis
suchalowsite)
Rate:2040beatsperminute;candropbelow20beats
perminute
PWave:None
PRI:None
QRS:Wideandbizarre;.12secondsorgreater

LethalRhythms

LethalRhythms
SuddenCardiacArrest

ACS
Cardiomyopathy
ElectrolyteAbnormalities
ProlongedQTSyndrome
RonTphenomenacanthrow
apatientintoVTachorVFib

LethalRhythms

V-Fib

Pulseless
V-Tach

LethalRhythms
Torsades

Asystole

NoPulse=PEA
(PulselessElectricalActivity)
RemembertodoCPR!

ECGTips
Utilizeyourresources
AnalyzetheRhythm
GetStrips

ThankYou
Questions

CentralMonitor
CodeSummaryonDefibrillator

Please
Pleasevisitthesitebelowfor
visit the site below for
detailedEKGlectures

Ab
AbnormalRhythm=a12Lead
l Rh h
12 L d
PutECGtogetherwithAssessment
Data

Pulses
CapRefill
BloodPressure
Lung/HeartSounds

TreatthepatientnottheRhythm!

www.statmedicaltraining.com/e_links/ecg.htm
Feel free to email me with any
questions
dobronyi.clayton@tchden.org

References
DaleDubin,RapidInterpretationofEKGs,6th.Edition@2000byCover
PublishingCompany,Tampa,Fl
GailWalraven,BasicArrhythmias,SixthEdition
2006byPearsonEducation,Inc.,UpperSaddleRiver,NJ
MyungPark&WarrenGuntheroth,HowtoReadPediatricECGs,Third
Edition @ 1992 by Mosby St Louis MO
Edition@1992byMosbyStLouis,MO
SusanDuszynski,PediatricECGInterpretation,ASelfStudyText,Third
Edition@2000bymaxiSHAREMilwaukee,WI
SpecialthankstoDr.MichaelSchafferandtheAttendings/FellowsinThe
ChildrensHospitalCardiacInstitute