ED Pathway for the Evaluation/Treatment of Chest Pain in Children without Known Cardiac Disease

ECG Tips

Potentially Concerning ECG Findings in Patients with Chest Pain

  1. Ischemia, Myocarditis or Pericarditis:
    • Pathologic ST Segment changes in 2 or more contiguous leads: More than 2mm above baseline
    • Abnormal T wave morphology and axis for age
    • Pathologic Q waves (more than 5mm deep and >40ms wide) in 2 or more contiguous leads 2, 3
    • Low Voltage QRS amplitude (5mm or less in all six limb leads)
  2. Right or Left Ventricular Hypertrophy:
    • Right Ventricular Hypertrophy:
      • Upright T wave between 4 days and Puberty in V1
      • Tall R V1 (>20-29 mm) and Deep S V6 (5-20mm)
      • qR pattern in V1
      • Right axis deviation for age
    • Left Ventricular Hypertrophy:
      • Tall R V6 (>25 mm) or Tall R V5 (>35mm) and deep S V1(>25mm)
      • Q in V6 > 4mm
      • Left axis deviation for age
  3. Prolonged QTc (calculated per Bazett's Formula) greater than or equal to 450 msec 1, 4. Note: Prolonged QTc in of itself rarely is an etiology for chest pain, these patients more often present with syncope
  4. Abnormal Rhythm from patient's baseline*
    • Including abnormal P wave axis (outside of 0-90 degrees) in setting of tachycardia
    • Wide QRS for age including a new bundle branch block*
  5. Frequent PVCs on a 12 lead ECG or multiform PVCs

*Assuming there is a prior ECG available