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The Pediatric Electrocardiogram

February 24, 2023

In the January issue of Pediatrics in Review, there is an excellent article that brings the pediatrician up to steam on what they should recognize from an electrocardiogram (EKG) (10.1542/pir.2021-005346). The article is beautifully written and informative.

The article notes that Dr Augustus Waller performed the first EKG in 1887 using a capillary electrometer that produced tiny but readable signals. In 1902, Dr Willem Einthoven used a string galvanometer to deliver information on 3 leads-Einthoven’s triangle. The string galvanometer offered much better amplitude and usefulness. The device took up 2 rooms and weighed 600 pounds. The patient put both arms and the left leg into separate buckets of saline that served as electrodes. Over time, companies slimmed the device down to a more useful size. In 1914, EKG was brought to the uS by Dr Paul Dudley White (of the Wolff Parkinson White syndrome fame), who was chief of cardiology at Massachusetts General Hospital. That device is now on display at the Dallas headquarters of the American Heart Association. Dr White is considered the father of US Cardiology. He was President Eisenhower’s cardiologist and was President and one of the founders of the American Heart Association in 1941. He was a superb preventive cardiologist and clinical researcher. (He also said that all tobacco should be used as fertilizer.)

Today we use computerized laptop devices that do not occupy 2 rooms. They are useful, but some context is necessary. The pediatric EKG provides good insight into the heart’s electrical information if it is accurately read, but one needs to beware of computer interpretations that are often written into the machine’s software mainly for adult cardiology patients. Always measure the QTc interval instead of relying on the software. Overinterpretation of LVH can lead to other testing that can become expensive and may not be very useful. For example, most now accept LVH as 30mm QRS elevation in V6 as valid. Some machines offer the computerized LVH diagnosis using less amplitude that can create confusion.

The main issues for a pediatric heart patient center around plumbing and electricity. Regarding electricity, the EKG is useful for rate, rhythm, and axis. The various disturbances of rhythm are well covered in the article, and I commend it for your careful consideration.

EKG does offer somewhat less predictive information regarding cardiac anatomy. As stated in the article, it is useful in predicting cardiomyopathy, anomalous origin of the left coronary artery from the pulmonary artery (q waves in I and aVL), tricuspid atresia in the cyanotic infant (LAD and LVH), and northwest QRS axis in atrioventricular septal defect and in dysplastic pulmonary valve stenosis. When you see these patterns in infants whom you are seeing in the nursery, you should refer them to a pediatric cardiology center where accurate echocardiography and quality interventional catheterization and surgical care can be obtained.

This article is a good overview of the EKG, including how to read and interpret; useful and clearly presented with excellent figures. I hope that you will find it useful. I did.

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