Category: Paeds

Paediatric ECG

Use the following chart as a quick checklist to review what’s normal and what’s not in a paediatric ECG. 

Remember:

  • Lead V4R in under5’s
  • Manually calculate QTc
  • WPW needs referral for ablation – increase risk of sudden death

If in any doubt discuss with paediatric registrar/senior. If in need of urgent interven:on then contact the paediatric cardiology team in LGI.

1. Placement of Leads: Precordial Leads

In young children, the right ventricle normally extends to the right side of the sternum. To appropriately display right ventricular potentials, ECGs for children in the under five-year age group must include an alternate lead (‘V4R’) on the right side of the chest at a point analogous to the left sided V4.

2. P Waves:

3. Axis:

In utero- high pulmonary pressures and a relatively thick Right Ventricle (RV) -> Initial Right Axis on ECG is normal and resolves after the first 6 months of life

QRS Axis Deviation

  • Chest leads in wrong position

     

RAD:

  • Newborns
  • RVH secondary to Right ventricular outflow tract obstruction eg: Pulmonary
    Stenosis ,Tetralogy Of Fallot, Noonans (characterized by mildly unusual facial features, short stature, heart defects, bleeding problems, skeletal malformations, and many others)
  • RBBB

 

LAD:

  • LBBB
  • LVH secondary to LVOTO (Left Ventricular Outflow Tract Obstruction) e.g. Aortic Stenosis, HOCM

 

Superior Axis

  • AVSD (Atrio ventricular septal defect – Trisomy 21)
4. QTc:

Manually calculate QTc – HERE

Normal QTc:

  • Infants less than 6 months = < 0.49 seconds.
  • Older than 6 months = < 0.44 seconds.

QTc is prolonged in:

  • Hypocalcaemia
  • Myocarditis
  • Long QT syndromes such as Romano-Ward Drugs

QTc is short in:

  • Hypercalcaemia
  • Congenital short QT syndrome
5. Ventricular Hypertrophy

6. T waves:
  • The precordial T-wave configuration changes over time
  • For the first week of life, T waves are upright throughout the precordial leads.
  • After the first week, the T waves become inverted in V1-3 (= the “juvenile T-wave pattern”)
  • This T-wave inversion usually remains until ~ age 8; thereafter the T waves become upright in V1-3.
  • However, the juvenile T-wave pattern can persist into adolescence and early adulthood (= “persistent juvenile T waves”).

Tall, peaked T waves are seen in:

Hyperkalaemia, Dilated LV (volume overload), Benign early repolarisation

 

Flat T waves are seen in:

Normal newborns, Hypothyroidism, Hypokalaemia, Pericarditis, Myocarditis

7. ST Segment:

Some ST changes may be normal:

  • Limb lead ST depression or elevation of up to 1mm (up to 2mm in the left precordial leads).

  • J-point depression: the J point is depressed without sustained ST depression, i.e. upsloping ST depression

  • Benign early repolarisation in adolescents: the ST segment is elevated and concave in leads with an upright T wave.

 

 

Others are pathological:

  • A downward slope of the ST followed by a inverted T.

  • A sustained horizontal ST segment depression

     

 

Pathological ST segment changes are commonly associated with T wave changes and occur in:

  • Pericarditis.

  • Myocardial ischaemia or infarction.

  • Severe ventricular hypertrophy (ventricular strain pattern)

Thanks to the paediatric dept for supplying the guidance –  trust PDF here

Swallowed Foriegn Body

The ingestion of a foreign body or multiple foreign bodies (FB) is a common presenting complaint in paediatric surgery, with a peak incidence from 12-24 months however, can occur at any age. Ingested foreign bodies rarely cause problems; almost 80% of patients pass the foreign body without intervention – in seven days2 (only 1% require surgical removal). However, occasionally foreign bodies can cause significant morbidity (for example, oesophageal rupture) and 1% require surgical removal.

The presenting symptoms and outcomes of an ingested foreign body is highly dependent on the swallowed object, and for this reason, the guidance for hazardous and non-hazardous foreign body ingestion has been divided accordingly.

Using the Metal Detector

Non-Hazardous Objects

Button Battery

Magnets

 

Sharp Objects

PDF copy – HERE

Neonatal Seizures

Seizures are a common neurological emergency in the neonatal period, occurring in 1–5 per 1000 live births.1 The majority of neonatal seizures are provoked by an acute illness or brain insult with an underlying aetiology either documented or suspected, that is, these are acute provoked seizures (as opposed to epilepsy). They are also invariably focal in nature.

Clinical diagnosis of neonatal seizures is difficult. This is in part because there may be no, or very subtle, clinical features, and also because neonates frequently exhibit non-epileptic movements that can be mistaken for epileptic seizures.

Read more

Measles

Suspected/Confirmed patients should be ISOLATED & wear PPE 

Treating Staff – (should not be; non-immunised, pregnant or immunocompromised)

  • single-use, disposable gloves
  • single-use, disposable apron (or gown if extensive splashing or spraying, or performing an aerosol generating procedure (AGP))
  • FFP3 – respiratory protective equipment (RPE)
  • eye/face protection (goggles or visor)

Patient

  • Surgical face mask

Background

  • Measles is highly infectious – (4 day prior to and after rash appears) suspected patients should be isolated within the ED
  • Measles Immunisation – 1 dose 90% effective, 2 doses 95% effective
  • Measles is a notifiable disease
EM3

Read more

Minimal and Moderate Paediatric Sedation

The depth and type of sedation required in children depends on the procedure to be carried out.

Sedation is described as:

Minimal – Drug induced calm, the patient is awake and responds to verbal commands but may have impairment of cognition and coordination.

Moderate – Drug induced depression of consciousness but patients respond purposefully to verbal commands or tactile stimulation.

Deep – Drug induced depression of consciousness during which patients are asleep and cannot be easily roused, respond to painful stimuli.

Dissociative – Ketamine Sedation produces a trance like state.

 

Painful procedures preformed for children in the ED are usually done with Ketamine Sedation for which there is a separate pathway – Ketamine Sedation

 

Minimal and Moderate Sedation

Painless procedures such a diagnostic imaging do not require Ketamine or Opioids therefore drugs such as oral Chloral Hydrate or Buccal Midazolam should be considered, neither of these require cannulation.

Who can preform minimal/moderate sedation?

  • Senior medical staff (ST3+) with paediatric life support training
  • Must have done at least 6 months of anaesthetics/ICU
  • Familiar with giving medication of choice
  • Must have at least 2 staff members – someone to perform sedation, someone to monitor the patient
  • Department must be safe – Senior ED Clinician in charge (Consultant or Senior Registrar when Consultant not present in department has final say over if it is appropriate to perform at any given time.

Contraindications

Any of the following comorbidities / contraindications require discussion with an anaesthetist / senior paediatrician:

  • Abnormal airway – including large tonsils or craniofacial anomalies e.g. receding jaw, stiff neck, restricted mouth opening, very large head
  • Raised intra cranial pressure or depressed conscious level
  • History of obstructive sleep apnoea
  • Major organ dysfunction including congenital cardiac anomalies
  • Moderate to severe gastro oesophageal reflux disease
  • Neuromuscular disorders
  • Bowel obstruction
  • Intercurrent respiratory tract infection
  • Known allergy to sedative drug / previous adverse reaction
  • Multiple trauma
  • Refusal by parent / guardian / child
  • Corrected age < 1 year because of severe prematurity
  • ASA 3 or more

Fasting

  • For an emergency procedure in a child or young person who has not fasted, balance the risks and benefits of the decision to proceed with sedation before fasting criteria are achieved, on the urgency of the procedure and the target depth of sedation. Consider discussing this child with an anaesthetist.
  • Apply the 2-4-6 fasting rule for ketamine sedation in the ED if safe and appropriate for the procedure to wait for this:
    • 2 hours for clear fluids
    • 4 hours for breast milk
    • 6 hours for solids and formula milk

Medications

Chloral Hydrate

Oral – give 45-60 minutes before procedure, it has an unpleasant taste but can be mixed with blackcurrant squash

Dose: –

Minimal Sedation: 30-50 mg/kg Maximum 1g

Moderate Sedation: 100mg/kg Maximum 2g

Side Effects

Gastric irritation including nausea and vomiting reported.

Beware cardiac arrhythmias and respiratory depression with loss of airway reflexes at high doses.

There is NO reversal agent available

Buccal Midazolam

Buccal: Give 15 minutes pre-procedure and give half the dose into each side of the mouth

Dose: –

1-9 years:  0.2mg – 0.3mg/kg; Maximum 5mg

10-18 years:  6mg – 7mg; Maximum 8mg if 70kg or over

Side Effects

Short acting benzodiazepine causing sedation, hypnosis, anxiolysis, anterograde amnesia

Beware respiratory depression / hypotension / loss of airway reflexes at high doses.

Can lead to a distressing paradoxical excitement in children

Reversal agent: Flumazenil

Flumazenil dose: 10 microgram/kg [Max 200 microgram], repeat at 1 minute intervals up to 5 times.

 

Post sedation care

  • Observe for 1-2 hours until:
    • Conscious and responding appropriately
    • Able to walk unassisted (older children)
    • Vital signs are within normal limits
    • Respiratory status not compromised
    • Pain and discomfort addressed
  • No food or drink for 2 hours after discharge (risk of nausea and vomiting)
  • Supervise child closely for 24 hours no driving for older children
  • Give advice leaflet to parents/carer
  • Ensure that sedation documented on EPR and drugs are signed for in CD book

Full trust policy is available on intranet here