• Electrocardiography is critical in the diagnosis of electrical disorders of the heart. It may serve as a useful screening tool in the evaluation of patients of suspected structural defects or abnormalities of the myocardium.
  • Newborns have a large variability in electrocardiogram (ECG) voltages and intervals due in large part to hemodynamic and myocardial adaptations that are needed once the placenta is no longer part of the circulatory system.
  • Changes continue, albeit at a slower pace, from infancy through adolescence.
  • Algorithms used to interpret ECGs in adults cannot be used in children. This section is a basic, although incomplete, guide to the pediatric ECG.
Rate
  • The usual recording speed is 25 mm/sec; each little box (1 mm) is 0.04 seconds and each big box (5 mm) is 0.2 seconds.
  • With a fast heart rate, count the R-R cycles in 6 large boxes (1.2 seconds) and multiply by 50.
  • With a slow heart rate, count the number of large boxes between R waves and divide into 300 (1 box = 300, 2 boxes = 150, 3 boxes = 100, 4 boxes = 75).
  • Table below lists normal heart rates.
Rhythm
  • Are the QRS deflections regular? Variation in the rate up and down in concert with respirations is normal (sinus arrhythmia) and can be pronounced in young healthy hearts.
  • Irregular QRS pattern suggests the possibility of an atrial arrhythmia. With pauses and narrow QRS, look for evidence of atrial premature contractions with P waves of different of appearance and/or axis as compared with sinus beats. The early P wave may not conduct, leading to longer pauses (blocked atrial premature contractions).
  • The QRS may be prolonged if conduction down the atrioventricular (AV) node is delayed (aberrant conduction). Wide QRS complexes with pauses may represent premature contractions from a ventricular focus, especially if the T-wave morphology is also altered Continue reading »
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Atrial flutter, also known as intra-atrial re-entrant tachycardia, is a regular or regularly irregular tachycardia characterized by atrial activity at a rate of 250–400 beats/min. These contractions are thought to be due to a re-entrant or circus rhythm originating in the atria and involving a micro-re-entrant loop within the atrial tissue and some form of anatomic obstacle that creates a discontinuity in conduction (fibrosis, surgical suture site, valve annulus). Because the AV node cannot transmit such rapid impulses, some degree of AV block is virtually always present, and the ventricles respond to every 2nd–4th atrial beat. Occasionally, the response is variable and the rhythm appears irregular.

In older children, atrial flutter usually occurs in the setting of congenital heart disease; neonates with atrial flutter frequently have normal hearts.

Atrial flutter may occur during acute infectious illnesses but is most often seen in patients with large stretched atria, such as those associated with long-standing mitral or tricuspid insufficiency, Continue reading »

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Kawasaki disease (KD), formerly known as mucocutaneous lymph node syndrome and infantile polyarteritis nodosa, is an acute febrile vasculitis of childhood.

Kawasaki disease is the leading cause of acquired heart disease in children in the United States and Japan.

Fever is characteristically high (104°F or higher), remittent, and unresponsive to antibiotics. The duration of fever without treatment is generally 1–2 wk, but it may persist for 3–4 wk. Prolonged fever is prognostic for the development of coronary artery disease.

In addition to fever, the five characteristic features of Kawasaki disease are: bilateral bulbar conjunctival injection, usually without exudate; erythema of the oral and pharyngeal mucosa with strawberry tongue and dry, cracked lips, and without ulceration; edema and erythema of the hands and feet; rash of various forms (maculopapular, erythema multiforme, or scarlatiniform) with accentuation in the groin area; and nonsuppurative cervical lymphadenopathy, usually unilateral, with node size of ?1.5 cm.

Perineal desquamation is common in the acute phase. Periungual desquamation of the fingers and toes begins 1–3 wk after the onset of illness and may progress to involve the entire hand and foot.

Other features include extreme irritability that is especially prominent in infants, aseptic meningitis, diarrhea, mild hepatitis, hydrops of the gallbladder, urethritis and meatitis with sterile pyuria, otitis media, and arthritis. Arthritis may occur early in the illness or may develop in the 2nd–3rd week, generally affecting hands, knees, ankles, or hips. It is self-limited but may persist Continue reading »

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