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Pediatric Dysrhythmias Leanna Miller Pediatric Dysrhythmias

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					                        Pediatric Dysrhythmias                  Pediatric  Dysrhythmias
                                                                     Introduction
                                                            • Overall incidence of pediatric
                                                              dysrhythmias is low
                                                            • Most common dysrhythmias in
                                                              children
                                                              – Sinus tachycardia (50%)
         Leanna R. Miller                                     – Supraventricular tachycardia (13%)
         RN, MN, CCRN-CMC, PCCN,-CSC CEN, CPNP                – Bradycardia (6%)
                 Educator – CVICU                             – Atrial fibrillation (4.6%)
        Vanderbilt University Medical Center
                   Nashville, TN




                         Pediatric  Dysrhythmias                Pediatric  Dysrhythmias
                          Introduction                               Introduction
                  • Most common reasons to                  • Most common reasons to
                    obtain a 12 lead EKG in                   obtain a 12 lead EKG in
                    children are:                             children are:
                     – Chest pain                             – drug exposure
                     – Suspected dysrhythmias                 – electrical burn
                     – Seizures                               – electrolyte abnormalities
                     – Syncope                                – abnormal physical assessment
                                                                findings




                         Pediatric  Dysrhythmias                Pediatric  Dysrhythmias

                     Behavioral Objectives                    Electrocardiography
             • The participant will be able to:
                                                             algebraic sum of all action
                 – Analyze clinical signs & symptoms, lab
                   data
                   d t & EKG findings in pediatric
                                fi di    i    di t i          potentials
                   patients with dysrhythmias                summation of voltage
                 – Correlate pathophysiologic findings to
                   EKG changes in pediatric patients         12 different pictures of
                 – Evaluate management strategies for         electrical activity in 2
                   the treatment of pediatric                 planes
                   dysrhythmias




leanna.miller@vanderbilt.edu                                                                         1
                      Pediatric  Dysrhythmias                            Pediatric  Dysrhythmias
                               Normal ECG
                                                                P wave
                                                                      2.5 mm amplitude
                                                                      0.11 second in width
                                                                PRI (PR interval)
                                                                      0.12 - 0.20 second
                                                                       delay in AV node
                                                                       bundle branch disease
                                                                       metabolic effects of drugs




                      Pediatric  Dysrhythmias                            Pediatric  Dysrhythmias

                           AGE                 PR Interval                   AGE                 PR Interval

                         1st   week            0.08 – 0.15                3 – 4 years            0.09 – 0.17

                                k
                       1 – 3 weeks             0.08 0.15
                                               0 08 – 0 15                5 – 7 years            0.09 – 0.17

                       1 – 2 months            0.08 – 0.15
                                                                         8 – 11 years            0.09 – 0.17
                       3 – 5 months            0.08 – 0.15
                                                                         12 – 15 years           0.09 – 0.18
                      6 – 11 months            0.07 – 0.16
                                                                          > 16 years             0.12 – 0.20
                       1 – 2 years             0.08 – 0.16




                      Pediatric  Dysrhythmias                            Pediatric  Dysrhythmias

            QRS Complex                                            T wave
              < ¼ of the R wave; < 0.04                               ventricular depolarization
               seconds width                                           epicardial to endocardial
              0.06 to 0.11 seconds in width                           0.10 - 0.25 seconds
              septum is 1st to depolarize                               electrolyte abnormalities
              depolarization from inferior                              drug imbalances
               to superior surface produces                              myocardial ischemia or infarction
               small Q Wave in II, III, aVF




leanna.miller@vanderbilt.edu                                                                                   2
                  Pediatric  Dysrhythmias                        Pediatric  Dysrhythmias

                          Case Study 1                                  Case Study 1
               A 3 – year – old girl was brought to          The EKG was notable for sinus
                the ED by her parents due to 3                 tachycardia with a rate of 112 and
                days of poor feeding, vomiting,                inverted T waves in leads V1, V2,
                diarrhea. On exam, she appeared                and V3. Findings are consistent
                well – developed, fussy toddler                with a normal juvenile pattern. An
                with no significant physical                   outpatient ECHO shows no
                findings other than a 2/6 systolic             significant abnormalities.
                murmur radiating to the base




                  Pediatric  Dysrhythmias                        Pediatric  Dysrhythmias

                                                            ST segment
                                                              should be at isoelectric line
                                                                elevation > 1 mm above baseline
                                                                depression < 0.5 mm below
                                                                  baseline
                                                              sensitive indicator of myocardial
                                                               injury or ischemia
                                                              point from ST & QRS is J point




                  Pediatric  Dysrhythmias                        Pediatric  Dysrhythmias
                                                                    Fast & Dirty Approach
                        QT Interval (QTI)
                beginning of QRS to end of T wave
                usually no more than ½ of R - R
                      ll          th        f
                 interval
                variable length related to heart rate
                important to use QTc




leanna.miller@vanderbilt.edu                                                                        3
                     Pediatric  Dysrhythmias        Pediatric  Dysrhythmias

        Hexaxial Reference System
          determine most isoelectric
          determine perpendicular
           lead, plot it
          lead with greatest voltage,
           plot it
          if #3 is different from #2,
           axis lies between




                     Pediatric  Dysrhythmias        Pediatric  Dysrhythmias




                     Pediatric  Dysrhythmias        Pediatric  Dysrhythmias

                         AGE             QRS Axis       AGE         QRS Axis

                       1st   week        60 – 180    3 – 4 years     0 – 110

                               k
                      1 – 3 weeks        45 – 160    5 – 7 years     0 – 110

                     1 – 2 months        30 – 135
                                                    8 – 11 years    -15 to 110
                     3 – 5 months        0 – 135
                                                    12 – 15 years   -15 to 110
                     6 – 11 months       0 – 135
                                                     > 16 years     -15 to 110
                      1 – 2 years        0 – 110




leanna.miller@vanderbilt.edu                                                     4
                 Pediatric  Dysrhythmias            Pediatric  Dysrhythmias

                                              Right Atrial Enlargement (RAE)
                                               •1st portion of P wave increases in
                                               amplitude to 3 mm or greater
                                               •duration     does not increase
                                               •may cause P wave axis to shift
                                               rightward
                                               •called   P pulmonale




                 Pediatric  Dysrhythmias            Pediatric  Dysrhythmias

                                              Left Atrial Enlargement (LAE)
                                               •2nd portion of P wave may increase in
                                               amplitude or increase the duration of
                                               the P wave
                                               •called P mitrale – often caused by
                                               mitral valve disease
                                               •correlated   with clinical findings




                 Pediatric  Dysrhythmias            Pediatric  Dysrhythmias




leanna.miller@vanderbilt.edu                                                            5
                           Pediatric  Dysrhythmias                                    Pediatric  Dysrhythmias

             Right Ventricular Hypertrophy (RVH)
               •   limb leads – right axis deviation (QRS in
                   lead I is more negative than positive)
               •   loss of R wave progression
                    –   V1, the R wave larger than S wave
                    –   V6, the S wave larger than R wave




                           Pediatric  Dysrhythmias                                    Pediatric  Dysrhythmias

                                                                      Right Ventricular Hypertrophy (RVH)
                                                                       •   increased voltage of r waves in right
                                                                               precordial leads (V1 – 2)

                                                                       • increased voltage of s waves in left

                                                                               precordial leads (V5 – 6)




                           Pediatric  Dysrhythmias                                    Pediatric  Dysrhythmias

                                                                      Right Ventricular Hypertrophy (RVH)
             Right Ventricular Hypertrophy (RVH)
                                                                           •   S – T & T wave changes in right
              •    common causes include:
                                                                               precordial leads (V1 – 2)
                    –   pulmonary disease
                                                                           •   RAD +100 or more
                    –   congenital heart disease
                                                                           •   VAT > 0.02 in (V1 – 2)




leanna.miller@vanderbilt.edu                                                                                       6
                     Pediatric  Dysrhythmias                       Pediatric  Dysrhythmias




                     Pediatric  Dysrhythmias                       Pediatric  Dysrhythmias


                                                  Left Ventricular Hypertrophy (LVH)
                                                   •   common causes include:
                                                        –   valvular heart disease
                                                        –   congenital heart disease




                     Pediatric  Dysrhythmias                       Pediatric  Dysrhythmias


       5 points diagnostic
                                                           Strain Pattern
       4 points probable                                     •   ST segment depression
                                                             •   T wave inversion




leanna.miller@vanderbilt.edu                                                                 7
                            Pediatric  Dysrhythmias     Pediatric  Dysrhythmias


                      Strain Pattern
                       •   RVH seen in V1 - 2
                       •   LVH seen in I, aVL, V5 - 6




                            Pediatric  Dysrhythmias     Pediatric  Dysrhythmias

             Right Ventricular Hypertrophy (RVH)
              •r   waves increased in V1 & V2
              •s   waves increased in V5 & V6
              •S    – T & T wave changes in right
                   precordial leads (V1 – 2)
              •   RAD +100 or more
              •   VAT > 0.02 in (V1 – 2)




                                                        Pediatric  Dysrhythmias



      5 points diagnostic
          i t di      ti
      4 points probable




leanna.miller@vanderbilt.edu                                                      8
                        Pediatric  Dysrhythmias                            Pediatric  Dysrhythmias

                        Congenital Heart Disease              CHD    RVH    LVH   RAE    LAE    RAD   LAD      RBBB

                  occurs in 8 out of every 1000 live         PDA            +
                   births
                                                              ASD     +            +             +              +
                  EKG is not diagnostic
                                                              VSD     +      +                           +      +
                   provides important clues
                   chamber enlargement,                      CoA     +      +                   +

                     conduction abnormalities                 ToF     +                          +              +




                        Pediatric  Dysrhythmias                            Pediatric  Dysrhythmias

           CHD    RVH    LVH   RAE   LAE   RAD   LAD   RBBB                Congenital Heart Disease
           TGA     +                        +                        RVH
          HLHS     +                        +                            most
                                                                      most common ECG finding in
                                                                        patients with CHD
           AS             +
                                                                      RV predominance in the early
           PS      +            +           +                           neonatal period
          HCM             +          +                                RVH may be overlooked until
                                                                        late infancy




                        Pediatric  Dysrhythmias                            Pediatric  Dysrhythmias

                               RVH seen in:                                Congenital Heart Disease
                  PS                                                LVH seen in lesions with LV outflow
                                                                      tract obstruction
                  ToF
                                                                      AS C A
                                                                      AS, CoA
                  TGA                                               LVH can be seen in patients with a
                  VSD with PS or pulmonary HTN                       small RV
                  CoA                                                 tricuspid atresia, pulmonary atresia
                  HLHS                                              other reasons for LVH include:
                                                                      large VSD, PDS (older children)
                  ASD




leanna.miller@vanderbilt.edu                                                                                          9
                  Pediatric  Dysrhythmias                     Pediatric  Dysrhythmias

               Hypertrophic Cardiomyopathy                Hypertrophic Cardiomyopathy
            asymmetric, non-dilated ventricular       ECG findings include:
             hypertrophy – most found within the          LAE
                                                        LAE & LVH
             septum                                     ST – segment abnormalities
            rhythm disturbances include:               T wave inversions
              PACs, or PVC                             narrow Q-waves
              multifocal ventricular dysrhythmias      small R waves in lateral leads
              new onset atrial fibrillation




                  Pediatric  Dysrhythmias                     Pediatric  Dysrhythmias

                      Kawasaki Disease                            Kawasaki Disease
               acute, self- limited vasculitis           EKG changes include:
               occurs in infants and young                  classic
                                                           classic ST, T wave and Q wave
                children                                     changes
               s/s: fever, conjunctivitis, rash,          T wave flattening or peaking
                erythema of oral mucosa and lips,          PR and QT prolongation
                swelling of extremities, cervical
                lymphadenopathy




                  Pediatric  Dysrhythmias                     Pediatric  Dysrhythmias

                      Kawasaki Disease                             Case Study 2
               15 to 25% develop coronary artery     A 7 – month – old girl is brought to the
                aneurysms  myocardial ischemia        ED with a history of 5 days of fever,
                and infarction                         cough, and rhinorrhea. Her exam is
               leading cause of acquired heart        remarkable for bilateral conjunctivitis,
                disease in children                    injected pharynx & fissured lips, cervical
                                                       adenopathy, and a non-specific rash
                                                       involving hands and feet.




leanna.miller@vanderbilt.edu                                                                        10
                   Pediatric  Dysrhythmias                     Pediatric  Dysrhythmias

                                                           Supraventricular Tachycardia
                                                        most common pediatric tachycardia
                                                        Occurs 1:250 & 1:1000 pediatric patient
                                                        Usually during 1st 2 months of life
                                                         fussiness, poor feeding, lethargy
                                                         chest pain, shortness of breath,
                                                           dizziness




                   Pediatric  Dysrhythmias                     Pediatric  Dysrhythmias

                        Case Study 3
            An 11 – month – old girl is brought to
             the ED for poor feeding, irritability &
             lethargy. Well-developed infant in mild
             distress, pulse rate > 200 but
             otherwise stable with lungs clear on
             auscultation. 12 lead shows narrow
             complex QRS with rate of 280. Treated
             with adenosine.




                   Pediatric  Dysrhythmias                     Pediatric  Dysrhythmias

                   Wolff Parkinson White
            accessory pathway between atria and
             the ventricles
            EKG findings include:
              wide QRS complex with delta wave
              short PR interval
              evidence of repolarization ST
               segment/T wave abnormalities




leanna.miller@vanderbilt.edu                                                                       11
                   Pediatric  Dysrhythmias                    Pediatric  Dysrhythmias

                        Case Study 4
            A 9 – year – old boy presents to the ED
             with c/o palpitations. He has a history
             of recurrent palpitations associated
             with weakness in the past. Physical
             exam is unremarkable. The EKG
             revealed evidence of a delta wave
             before the QRS complex. The patient
             was diagnosed with Wolff-Parkinson-
             White Syndrome.




                   Pediatric  Dysrhythmias                    Pediatric  Dysrhythmias




                   Pediatric  Dysrhythmias                    Pediatric  Dysrhythmias

                     Long QT Syndrome                           Long QT Syndrome
             incidence: 1:7000                         Signs & Symptoms
             deaths: 3,000 to 4000/year                    unexplained
                                                         unexplained fainting
             congenital – detected by age 12            unexplained seizures
             more common in women than men              near drowning
             common in children born deaf               sudden cardiac death
                                                         noisy gasping while sleeping




leanna.miller@vanderbilt.edu                                                             12
                   Pediatric  Dysrhythmias                       Pediatric  Dysrhythmias




                   Pediatric  Dysrhythmias                       Pediatric  Dysrhythmias

                                                                  Long QT Syndrome
                                                         Treatment
                                                             make
                                                           make lifestyle changes
                                                           avoid medications that may trigger
                                                            symptoms
                                                           take medications which reduce risk of
                                                            rhythm
                                                           surgery




                   Pediatric  Dysrhythmias                       Pediatric  Dysrhythmias

                       Case Study 5
         1 week old infant brought to ED due to
          lethargy, respiratory distress and “turning
          blue”. She was in respiratory distress and
          hypotensive on arrival. Cardiac exam noted
          a faint systolic murmur. An ECG revealed a
          marked RVH with strain. The ECHO
          revealed hypoplastic left heart syndrome.
          She was started on prostaglandin infusion.




leanna.miller@vanderbilt.edu                                                                        13
                    Pediatric  Dysrhythmias                          Pediatric  Dysrhythmias

                       Case Study 6
         A 6 – week – old infant was referred to ED
          for poor feeding and irritability over the
          past week. On exam, she was stable, but
          has rales on auscultation and a grade 3/6
          systolic murmur and a higher 2/6 diastolic
          murmur. The ECG has LVH, LAD. Chest x-
          ray had cardiomegaly and increased
          pulmonary vascular markings. On ECHO
          diagnosed VSD.




                    Pediatric  Dysrhythmias                          Pediatric  Dysrhythmias

                        Case Study 7
           A 15-year-old boy presented to the ED c/o
            dizziness and weakness. Past medical
            history significant for repair of ToF. A
            diuretic was recently added. Cardiac
            exam revealed a loud 3/6 systolic murmur
            heard best at the base. An EKG revealed
            biatrial enlargement, RAD & an IVCD.
            Patient admitted for hypovolemia.




                    Pediatric  Dysrhythmias                          Pediatric  Dysrhythmias
                                                                             References
                      IN CONCLUSION                     • Amin AS, Tan HL, Wilde AA.  Cardiac ion channels in health and 
               • overall incidence of pediatric           disease.  Heart Rhythm. 2010;7(1):117‐126.

                 d h th i is low
                 dysrhythmias i l
                                                          Clarke CJ, McDaniel GM.  The risk of long QT syndrome in the 
                                                        • Clarke CJ McDaniel GM The risk of long QT syndrome in the
                                                          pediatric population.  Curr Opin Pediatr. 2009;21:573‐578.

               • signs & symptoms are subtle            • Collins KK, VanHare GF.  Advances in congenital long QT syndrome.  
                                                          Curr Opin Pediatr. 2006;18:497‐502.
                 and vague                              • Evans – Murray A.  Wolff Parkinson White (WPW) syndrome:  What 
                                                          the critical care nurse needs to consider when administering 
               • life – threatening                       antiarrhythmics.  Aust Crit Care.2001;14(1):5‐9.




leanna.miller@vanderbilt.edu                                                                                                    14
                      Pediatric  Dysrhythmias
                                 References
              • George AL.  Common genetic variants in sudden cardiac death.  
                Heart Rhythm. 2009;6(11S):S3‐S9.
                                     A, Kluger J, Maron BJ, Thompson PD.  The 
              • Kapetanopoulos A Kluger J Maron BJ Thompson PD The
                congenital long QT syndrome and implications for young 
                athletes.  Med Sci Sports Exerc. 2006;38(5):816‐825.
              • Moss AJ, Zareba W, Hall WJ, Schwartz PF, Crampton RS et al.  
                Effectiveness and limitations of ‐blocker therapy in congenital 
                long – QT syndrome.  Circulation. 2000;101:616‐623.
              • Thanavaro JL, Thanavaro S.  Clinical presentation and treatment 
                of atrial fibrillation in Wolff – Parkinson – White syndrome.  
                Heart & Lung. 2009; (In Press):1‐6.




leanna.miller@vanderbilt.edu                                                        15

				
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