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8/13/2019 Basic Paediatric Ecg
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INSTITUT JANTUNG NEGARANational Heart Institute
Dr Marhisham Che Mood
PCHC IJN
8/13/2019 Basic Paediatric Ecg
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8/13/2019 Basic Paediatric Ecg
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INSTITUT JANTUNG NEGARANational Heart Institute
The Anatomy of the Heart
The Coronary Circulation
8/13/2019 Basic Paediatric Ecg
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INSTITUT JANTUNG NEGARANational Heart Institute
The Anatomy of the Heart
The Coronary Circulation
8/13/2019 Basic Paediatric Ecg
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INSTITUT JANTUNG NEGARANational Heart Institute
The Heartbeat
Heartbeat Needs two Types of Cardiac Cells – Contractile cells
• Provide the pumping action
– Cells of the conducting system • Generate and spread the action potential
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INSTITUT JANTUNG NEGARANational Heart Institute
The Heartbeat
The Conducting System – Initiates and spreads electrical impulses in heart – Two types of cells
• Nodal cells – Pacemaker cells
» Reach threshold first» Set heart rate
• Conducting cells
– Distributes stimuli to myocardium
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National Heart Institute
The Heartbeat
The Conducting System (cont’d) – Heart is self-exciting
• Pacemaker cells establish heart rate – Normal pacemaker is sinoatrial (SA) node
• Impulse spreads from SA node: – Across atria – To atrioventricular (AV) node – To AV bundle and bundle branches
– Via Purkinje fibers to ventricles
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
The Heartbeat
The ConductingSystem of the Heart
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
SA node activity and atrialactivation begin.
Stimulus spreads across the atrialsurfaces and reaches the AV node.
There is a 100-msec delay at theAV node. Atrial contraction begins.
The impulse travels along the interventricularseptum within the AV bundle and the bundlebranches to the Purkinje fibers.
The impulse is distributed by Purkinje fibersand relayed throughout the ventricularmyocardium. Atrial contraction is completed,and ventricular contraction begins.
Time = 0
SA node
AV node
Elapsed time = 50 msec
Elapsed time = 150 msec
AV bundle
Bundle branches
Elapsed time = 175 msec
Elapsed time = 225 msec Purkinje fibers
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
SA node activity and atrialactivation begin.
Time = 0
SA node
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
SA node activity and atrialactivation begin.
Stimulus spreads across the atrialsurfaces and reaches the AV node.
Time = 0
SA node
AV node
Elapsed time = 50 msec
8/13/2019 Basic Paediatric Ecg
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Click to edit Master title styleINSTITUT JANTUNG NEGARA
National Heart Institute
SA node activity and atrialactivation begin.
Stimulus spreads across the atrialsurfaces and reaches the AV node.
There is a 100-msec delay at theAV node. Atrial contraction begins.
Time = 0
SA node
AV node
Elapsed time = 50 msec
Elapsed time = 150 msec
AV bundle
Bundle branches
8/13/2019 Basic Paediatric Ecg
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8/13/2019 Basic Paediatric Ecg
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Click to edit Master title styleINSTITUT JANTUNG NEGARA
National Heart Institute
SA node activity and atrialactivation begin.
Stimulus spreads across the atrialsurfaces and reaches the AV node.
There is a 100-msec delay at theAV node. Atrial contraction begins.
The impulse travels along the interventricularseptum within the AV bundle and the bundlebranches to the Purkinje fibers.
The impulse is distributed by Purkinje fibersand relayed throughout the ventricularmyocardium. Atrial contraction is completed,and ventricular contraction begins.
Time = 0
SA node
AV node
Elapsed time = 50 msec
Elapsed time = 150 msec
AV bundle
Bundle branches
Elapsed time = 175 msec
Elapsed time = 225 msec Purkinje fibers
8/13/2019 Basic Paediatric Ecg
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Click to edit Master title styleINSTITUT JANTUNG NEGARA
National Heart Institute
The Heartbeat
The Electrocardiogram (ECG or EKG) – A recording of the electrical activity of the heart – Three main components
• P wave
– Atrial depolarization• QRS complex
– Ventricular depolarization• T wave
– Ventricular repolarization
8/13/2019 Basic Paediatric Ecg
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8/13/2019 Basic Paediatric Ecg
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National Heart Institute
ECG Paper
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
The Heartbeat
Key Note
The heart rate is established by the SA node, as
modified by autonomic activity, hormones, ions,etc. From there, the stimulus is conductedthrough the atrium to the AV node, the AV bundle,the bundle branches, and Purkinje fibers to theventricular myocardium. The ECG shows theelectrical events associated with the heartbeat.
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
Lead Placement
The right arm or RA lead- directly below the clavicle & near the rightshoulderThe left arm or LA lead- directly below the clavicle & near the leftshoulderThe left leg or LL lead- on the left lower abdomen
8/13/2019 Basic Paediatric Ecg
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National Heart InstituteSteps to Interpreting Rhythm Strips
1. Evaluate the P wave Are the P wave present? Indicates atrialdepolarizationNormal shape? Upright and round
Are all the P wave the same shape?Do you see one P wave for each QRS complex?
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
2. Evaluate the Atrial RhythmMeasure the interval between two consecutive Pwaves (P to P interval)
Is the rate regular or irregular
Steps to Interpreting Rhythm Strips
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
3. Calculate the Heart RateCount the number of QRS complexes in a 6 secondrhythm strip and multiply by 10
Steps to Interpreting Rhythm Strips
6 X 10 = 60
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
4. Calculate the duration of the PR intervalCount the number of small boxes from thebeginning of the P wave to the beginning of theQRS complex and multiply by 0.04 secondsDoes the PR interval fall within normal limits?Is the PR interval constant in each QRS cycle?
Steps to Interpreting Rhythm Strips
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
5. Evaluate the ventricular rhythmMeasure the interval between two consecutive Rwaves. This is the R to R interval
Are the R to R intervals consistently the same?If the intervals are not the same, then the rhythm isconsidered irregular
Steps to Interpreting Rhythm Strips
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
6. Calculate the duration of the QRS complexCount the number of small boxes from thebeginning of the Q wave to the end of the S waveand multiply by 0.04 seconds
Are the complexes all the same size and shape?Do any of the QRS complexes appear different fromeach other?Is there one QRS complex for each P wave?
Steps to Interpreting Rhythm Strips
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
7. Evaluate the ST SegmentThe normal ST segment is flat or isoelectricThere can be an elevation or depression of 2mm or2 small boxes. This can be considered normal in
pediatrics. Abnormal changes are seen in pericarditis,myocardial ischemia or infarction
Steps to Interpreting Rhythm Strips
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
History:-Does the fast or slow heart rate start and stopsuddenly?Does it get worse with exercise?
Are there other symptoms? – difficulty breathing,pallor, cyanosis, dizziness, or poor feeding?What is the child’s activity level?
Family history
General Principles of EvaluatingChildren with Arrhythmias
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
How does the patient look?Is the patient breathing?Is there a pulse present?
General Principles of EvaluatingChildren with Arrhythmias
h h h d
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National Heart Institute
Rhythms originating in the sinus nodeSA node)
Rhythms originating in the sinus node (SA node)are:Normal Sinus RhythmSinus TachycardiaSinus Bradycardia
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
Characteristics of Sinus Rhythms
The characteristics are:
There is a P wave preceding each QRS complexThere is a regular PR interval
And the P wave is upright in lead II
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
Normal Sinus Rhythm
The normal rhythm for any age is sinus rhythm.
The average heart rate for infants is 90 to 160beats per minute and for children and teenagers,it is 65 to 100 beats per minute.
8/13/2019 Basic Paediatric Ecg
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National Heart Institute
Average Heart Rate per minute)
8/13/2019 Basic Paediatric Ecg
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National Heart Institute