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Hunter Phillips
Hunter Phillips

The ABC Of Pediatric ECG !!LINK!!

Emergency physicians attending to pediatric patients in acute care settings use electrocardiograms (ECGs) for a variety of reasons, including syncope, chest pain, ingestion, suspected dysrhythmias, and as part of the initial evaluation of suspected congenital heart disease. Thus, it is important for emergency and acute care providers to be familiar with the normal pediatric ECG in addition to common ECG abnormalities seen in the pediatric population. The purpose of this 3-part review will be to review (1) age-related changes in the pediatric ECG, (2) common arrhythmias encountered in the pediatric population, and (3) ECG indicators of structural and congenital heart disease in the pediatric population.

The ABC of Pediatric ECG

This note gives a concise approach to interpreting pediatric ECGs. It was created by Eric King, a medical student at the University of Alberta, and Dr. Karen Forbes, a pediatric hospitalist and medical educator at the University of Alberta. This infographic is based on the video series by Eric King, Dr. Forbes and Dr. Joseph Atallah, pediatric cardiologist at the Stollery Children's Hospital in Edmonton, Canada.

Long QT Identification of differences in the pediatric and adult ECG aid in distinguishing potentially life-threatening abnormalities from a normal ECG, with one of the most notable and vastly overlooked conditions being prolonged QT interval.

In this context, developing a first-of-kind pediatric ECG data warehouse is an important goal shared broadly across the biomedical community. This goal can benefit from the expertise that the FDA has with respect to adult patients in the purview of its ECG data warehouse. This expertise encompasses several elements, including 1) the development of community ECG standards; 2) the protection of patients from drug products that prolong heart muscle contraction; 3) the curation of high-volume data concerning drugs that affect heart function; and 4) the assessment of ECG characteristics as possible biomarkers to drive hypothesis generation.

We surveyed the PSGs to better understand their technical resources and pertinent workflow-information. Given the variability of methods and the ranges of data obtained by the PSGs, we developed a core set of essential data elements to promote uniform practices. Many PSGs have relied on paper forms for data collection. Therefore, we created a universal scannable form, in electronic and paper format, to enable direct digital data transfer to the data warehouse through software processing of images of the form. Because screenings performed by PSGs most frequently involve volunteer staff, we also developed materials to help train staff to perform standard ECGs in children and to capture high-quality data. Furthermore, to create a pediatric ECG data warehouse comparable in effectiveness to the current FDA (adult) ECG warehouse, the digital ECGs collected from children will be stored in the standardized (FDA-annotated ECG XML) format, amenable to all the analysis tools already in use with the current FDA (adult) ECG warehouse. The software developed to convert pediatric ECGs into the standardized format functions, moreover, regardless of the type of ECG machine used by any contributing PSG.

Leaders in pediatric cardiology at Duke and other institutions have worked with the FDA and the PSGs to implement a pilot project and promote a trajectory for the long-term establishment of the national data warehouse. Through this multidisciplinary collaboration, innovative tools have been developed for the harmonization of digital technology, empowering PSGs to collect standardized information from children and attain high-quality ECG data collection. Collaboration with the public has been essential in the creation of the database. Despite interruptions to their screening efforts owing to the COVID-19 pandemic, the PSGs provided almost 40,000 ECGs to the database to date.

Although data collection and data warehouse refinement are ongoing, the innovative tools described above, such as scannable forms and real-time transmission of ECG data to a central database, have already improved the efficiency and quality of data collection by PSGs. Beyond these improvements, the evolving first-of-kind pediatric ECG data warehouse promises significant public health advances, including the elaboration of clinical guidelines for assessing risk in children (including risk for SCDY), better pre- and post-market cardiac safety evaluation in children, and the development of biomarkers for use in pediatric clinical trials. Pediatric clinical trials in the context of abnormal heart rhythms have long been challenging, owing in part to uncertainties in the selection of endpoints and in the collection and interpretation of data from diverse screening sites. And after all, children cannot simply be regarded as small adults. Our efforts to create a pediatric ECG national data warehouse, encompassing the establishment of norms for the use of pediatric ECG markers, aim fundamentally to facilitate the execution of meaningful pediatric clinical trials and the rigorous assessment of pediatric cardiac safety signals.

The electrocardiogram (ECG), a cornerstone in the evaluation of children with acquired and congenital heart diseases, has the potential to be a useful tool and the basis of screening to prevent sudden cardiac death in the young. However, realizing that potential will require more reliable reference values for pediatric ECGs and a comprehensively better understanding of the role of the ECG in this setting. The National Institutes of Health-sponsored Pediatric Heart Network (PHN) is focusing closely on these goals through its Normal ECG Project, for which I am privileged to serve as the primary investigator. This article reviews the rationale for this project and the insights expected from it.

The variation in published data and the challenges of using the ECG to identify significant disease provided a strong motivation to obtain more reliable data and create an infrastructure to redefine the modern role of the ECG in the United States and Canada. The PHN, recognizing the dearth of information about normal pediatric ECGs as well as normal pediatric echocardiograms, has undertaken its Normal ECG Project in the hope of ultimately helping prevent sudden death in the young in North America.

Electrocardiography is typically the first cardiac test ordered in adult and pediatric patients presenting with potential cardiac abnormalities. Pediatric patients have unique physiology that rapidly changes from fetal to infant ages and then throughout childhood. These physiologic changes are reflected by changes in the electrocardiogram. In this lesson, we will review the basic principles and findings on the pediatric electrocardiogram.

There are many reasons why a pediatric cardiologist, like the specialists at the CHOC Heart Institute, may request a Holter monitor or event monitor for a patient, including but not limited to the following:

Left atrial enlargement (LAE) has been established as a marker for diastolic dysfunction in left-sided cardiac disease, and a surrogate measurement for conditions including patent ductus arteriosus, ventricular septal defects, mitral valve heart disease, and atrial fibrillation1,2. In the pediatric population, these conditions can be associated with significant morbidity and mortality in the absence of early intervention, thus necessitating the development of a reliable and standardized method of diagnosing LAE.

Currently, the gold-standard method for diagnosis is the echocardiogram3. In current clinical practice, pediatric patients who are suspicious for LAE often receive both echocardiograms and electrocardiograms (ECG) concurrently. In this method, ECGs are used only to exclude the presence of other cardiological diseases. However, given the comparatively wider access and lower economic cost of ECGs compared to echocardiography, it has been hypothesized that ECGs can be used as a screening test to identify patients who would benefit from further investigation. The development of a standardized guideline for LAE diagnosis using ECGs would help inform the decisions of physicians in rural or developing regions regarding referral to larger centers for specialized pediatric echocardiography. Additionally, identification of patients who do not benefit from further echocardiographic testing would minimize patient risks associated with unnecessary medical testing, decrease wait-times, and allow for a more efficient use of healthcare resources.

The records of all pediatric patients seen at McMaster University Medical Centre between 2013 and 2015 for echocardiographic investigations were reviewed. A total of 624 patients were identified in which an ECG was conducted within 2 weeks of an echocardiogram positive for LAE. Of these, 132 patients were excluded from our study due to arrhythmias or poor ECG test quality that prevented an accurate assessment for ECG criteria. The study population ranged from newborn to 18 years of age at the time of their echocardiogram. The patient characteristics are displayed in Table 2. The most commonly diagnosed heart condition is left-to-right shunt, followed by vascular heart disease.

Although not currently validated in the pediatric population, these ECG criteria have long since been used in the adult population. Munuswamy et al. compared all 4 criteria used in our study to adult echocardiographic criteria and found very similar findings to that of the present study14. Similar to our study, they determined that a bimodal P wave with a duration of >40 msec in any lead had a sensitivity of 15% and a specificity of 100%. Additionally, their findings that P wave durations >110 msec had a sensitivity and specificity of 33% and 88%, and P:PR ratio >1.6 at 31% and 64% were also very much in line with our findings. However, their findings for the criteria involving a negative V1 P wave >40 msec varied greatly from the findings of the present study in that they reported a comparatively high sensitivity of 83% but similar specificity of 80%. Interestingly, a more recent study by Batra et al. investigating only V1 P wave >40 msec as a criterion for LAE in the adult population identified sensitivities and specificities of 54.4% and 57.14%15. The level of agreement between several criteria investigated in the present study and studies in the adult population may indicate greater similarities between populations than initially presumed. This agreement may therefore extend the generalizability of the extensive findings in the echocardiogram and ECG literature from the adult population to pediatric patients. 041b061a72


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