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I'm Christina. Thank you so much for coming to this presentation today. Um, it's called pediatric hCGs. And I like to think that they're Pandora's box is cause if you know, if you're not really sure where to start and where to go and what today you can open up a can of worms. So, um, because I'm really passionate about the CDs in about how the how the heart works in general, I thought about making a M short session today to help you. And first we'll understand how easy these work do. A bit of recap from that point of view, especially cause I'm mindful that I've got a wide variety of healthcare professionals joining today on developing a structured approach to when it comes to reading a CGs, um, and as but not least hopefully improving the confidence in spotting abnormalities on E. C. Gs and how to how to handle that? Um, a festival you hopefully know by now. But if you don't easy disease, capture the electrical activity admitted from the heart. Um, it's basically a movement of ions across cell membranes on. Dad is fundamentally responsible for the activity that happens, and within the heart and the EKG was invented many, many, many years ago, Um, in 18 95 on is surprisingly still used today. It's really quick, a really, really quick investigation that all of us should be able to get you. And that helps give you a picture, a very quick sort of like spot on picture of what the heart is doing from an electrical point of view at that point in time. And it, I think that made the biggest confusion that I've seen from from a lot of people when it comes to pediatrics, is how do you do any CT on a small human? And basically, it's just like an adult. You put the leads in the same place and preferably on a bone, rather than rather than a muscle for obvious reasons, cause muscles received their own electrical impulses. Um, Andi, For the smaller the child is, the smaller the stickers. You're going to need, um, what I sometimes do. And when the chest is too tight, knee is to get the usual stickers that we've got and just cut them with with a pair of scissors. Um, this really matter as long as you get a tiny bit of electrode onto onto the chest wall, um, or limbs. Her skin is really difficult to attach. Stickers to newborns really, really difficult to stick a CD stickers on, um, Andi when it comes to, um, having any CDs and ideally, the patient shouldn't be moving on. Shouldn't be talking. Um, maybe because the more you move, the more artifact you cause. So for a baby Oh, I found really east was two. Swaddle them, um, or to use supersize, for example, um, or another Children destruction. Do anything as what it that you can for that one second of capturing any C j A N e c G pattern. If somebody is sweaty, um, I found really useful is to use up sites, spray something that's worth looking for any award just to spray it on to on to the skin. Obviously careful not to scare the child to just make them aware that you're going to do that. Um, and stick them, stick them on that way and on. Obviously, it's sort of like how to put the limb lease on the Procardia leads. Like I said, they're literally the same as an adult and whether you put them on the shoulders or on the distal side of the arms. It doesn't really matter as long as you have more or less the same you do. You do the same thing on both sides. So rather than putting it on the right shoulder and left rest, make sure that you do it either both shoulders or both wrists. If that makes sense on the same, same with the legs. Cristina. What is upside spray for those that don't know? Um, it's a spray that dry. Well, to be honest, I don't really know what what exactly you can use it for. Other than drying the skin. I've not used it for anything else. I think it's meant to be clotting. The blood, isn't it? Or something like that? I don't really know. You know, I've only seen it used for the exact here. Drawing some swept for the seizures haven't actually. Yeah, literally the same. Um, we've I've seen it used after all. Pisa's well, for example, when we've done our pays and you just spray on, um, because technically it should have sort of like drying properties. I haven't released. I don't I don't bathe. Put it that way. I don't really know what the actual big purpose of it is other than being used for various. Strict. Okay, no worries me. I'll have a quick, uh, someone has commented. Actually, it's Ah, spray undressing. Thank you, Karen. Okay. Uh, well, you know, thank you and DC sort of knowing, say, for those of you from this presentation with might be really boring when if you know all this already, but for those of you don't really know the difference between electrodes and leave because we're gonna use the term leads quite a lot. Basically, your heart has loads and loads and loads back electrical activity within itself. Um, it's got a wire system coming from the main battery, which is s a note on basically, every single lead reads the sum of theoretical activity. So the some off those weights, the if the wave goes mainly or the main wave goes towards the electrode than the lead will be positive. If it goes away from the electrodes, then the further away it goes, the more negative it will be. Um, so hopefully that will help you understand what we're going to be talking about him in the next many slides and these leads and are based on where the electrodes are placed. So and now, how to actually read pediatric easy, Geez, on the cities in general. So first of all, it's really important to know who the patient is. When I was working, well, when I when I work on seeing you or in a day and when I used to work in any, you would be just handed a niece EGB and I Can you just sign C C J. Can you just look at the CT J? Um, And it used to be really confusing cause you can miss so much if you don't really know what why is that person had a knee surgeon? Who are they? And so knowing who the patient is is really important. How old are they? Have they got any symptoms? Is it something routine? Um, I tend to avoid to look a TC diesel to sign them. What to do? Anything. Unless I I actually have at least two minutes to get a bit more information about, um who the person is that I'm reading the CD off. Um, simply because my be seen as something routine. But actually, you can find one, find a lot of information from them as well as MS a lot of information knowing what settings the easy juice done on. So it should be set on a 10 millimeters per mil, a volt on the Y axis and 25 millimeters per second on the X axis. And you will see that at the bottom of the C g to make sure that those are the settings that your SED has done at because if not, that will alter what your SED is going to look like. Um, in terms of, um, height of voltages, um, artifacts, etcetera. Like I said, find out what the age of the child is, and we're going to talk about why in a second and and also the reason in terms of calculations, because we have, we're gonna have to do some months. Um, one small square is not point, not four seconds, and the large square is not 40.2 seconds. And don't worry if you don't remember this, Um, the more you do it, the more this will turn into a reflex. But if you don't do it often um, it's absolutely just the spine Teo to Google. How much A small square and how much a large square is on an E C G. Because I can promise you home many people forget from the beginning. Um, when it comes to reading any CJ, all of the all of the big pediatric cardiologists that you show any ZG to will be reading and ACG through the same structure. It might not seem like it because they don't work what they do out loud. But actually, everybody has a structure in terms of reading. Well, at least the biggest cardiologists have a structure when it comes to reading Easy. Geez, if you don't, you're more likely to forget more or less the same as we take histories. Now it's become a reflex. And the more mysteries you take, the quicker it gets. This is the This applies for a CGs is well, so a p waves present. Um, So is there a drill activity? And we'll talk about talk about people waving the second him. What's the right? Um on Is it written? Make? Is that rhythm or is it a Brit make and the way I tend to read the rate and it's something that I was taught in medical school doesn't really apply for. Everybody is I calculate the rate based on the big squares. So, um, if you start at the r wave, just like in the picture, um, on the second half, like lower half and and I count on 300 then 151 175 60. And that's per big, small pair, big square. Um, sort of like every bolded line is, um, a target. So 301 151 100. And if if that makes sense, it doesn't give you the exact list of numbers. But it gives you a rough idea as to what the heart rate is rather than having to take your calculator out. Um, in terms of the wives, it's really important other than whether they're present or not, whether what they look like, Um, if they are peaked, if they're humped, Um and hopefully this picture will help you understand why some people wives are peaked and why some people waves of humped. They have to hunts because mainly what we see on a normal E. C G is 11 p wave. But actually, if we were to zoom in a lot of not a lot into a P wave, it would actually have to very small, um hum ppsv because the essay node is located in your right atrium. So it obviously sends on the electrical impulse in the right atrium. First, um, and then with the tiny lag, the electrical impose impulse goes into the left atrium as well. And which is why, if you have a big right atrium, you're gonna need more power. Um, so your wave, the slower it's going to need to, um, the polarized atrium. So to activate the atrium, the taller your wave is gonna be a And if your left atrium is big, so therefore you're going to need a lot more power to activate your left atrium. The wider you're the second half the blue school, the blue triangle is going to be So therefore, you're going to see a hump or a lag. And there is it. Well, technically, we should be looking at the P wave axis is Well, it's quite important to look at that. But if you're doing the glanced reading of a any C J. That's, um you can get away without without doing that. Okay, so, um, because I thought about what would make this more interesting cause easy G's tend to be really dry. I've made a hoop whiz that we're going to be going back and forth to throughout the presentation to try and do a bit of practice is, Well, you don't have to know everything. That's why this presentation exists. Um, but hopefully they should make it fun. So grab you things open another, um, another browser gonna stop volume from my end. Um, so go on to a halt. Got it. Um, type the pin in Onda joined the game because we'll be doing some practice. Um, along the way, you can use nicknames. You don't have to use your actual name. Um, I usually use nicknames. And don't worry if you're not joining at that anybody conjoined at any point in time. So if it does look you out to kick you out, I feel free to join back in. That being said, I'm not really sure if there is an actual limit. How many people conjoined, Um but hopefully there isn't gonna be I'm gonna wait for a little bit longer. I'm going to start the, um, the game pin and the address is going to be present on the screen all throughout him. Today will be if you haven't. So we've got this E c J. What do you think roughly might be happening? We're obviously at the topic of peewee waves, and and there's no such thing that I'm not expecting you to know the answer. So the right answer was extracardiac. Let's go back to the presentation and think about why. So in dextrocardia, we have a reversal of the R wave progression on. Also, you have negative p waves in V one with a deranged P access. And the reason why that happens is if you have extra guardia and you put the leads in the normal place. Your atria is a gonna be mirrored. So the electrical activity is going to be captured in the opposite way in compared to having a heart on the left hand side, unless you put the leads on the right hand side. So if you put the leads as you used to putting them and the P wave is going to be negative because the electrical impulse, the mean of the electrical impulse. Instead of going towards the left hand side, as it would normally do, we'll go to the right hand side. So towards the apple, the mirror organization of the hot. Okay, everything is going to be a member ID. Say the opposite. No, we're gonna have a second question based on based on P waves. There is a syndrome has extra cardia is part of it is a very common question in the MRC PCH um, clinical well, in the MRC PCH exams again, Don't worry, if you don't know it was Qatargas say well done. For those 16 of you have answered, um, cartel gonna syndrome is a syndrome in which and extra cardia and actual actually citizen best scientists and versus totalis. It's part of a triad is well, as paranasal Sinuses, itis and bronchiectasis is. You would think you don't see it that often, But I teach medical students and for the second year exams, one of the patient that was brought for the examination was actually a 70 year old that probably, um, had Qatargas syndrome, and it was really interesting. So moving on from the P wave we've established that it is important to, um to think about how our atrium being charged with electric impulse, um, living on from the P wave, Um, towards the ventricles, we have the PR interval. So what happens in between the atrial charging on the ventricle, charging with electricity and Children, the more they grow on, bigger their bodies are on. The more mature their heart is, the more the heart rate changes. But, um, at the same time, a little components from a knee CG point of view, um, off their um p Q. R s said the Curis access changes that PR interval changes the cure us and terrible changes, etcetera. But do not worry, as long as you're aware that this is the case when you're going to see any C j a DCed, you'll know to look it up rather than rather than panic about it. Um, I don't really think anybody remembers the change in heart rate exactly for every single age range, Um, or at least I don't. My My memory with numbers isn't that good, but it's something to be aware of when it comes to, um, calculating your intervals. Um, next DC G. So we're at the topic of the PR interval. Technically, your PR interval shouldn't be more than three small squares. That's usually briefly what you should be looking at. That's what they teach you in adult medicine. Obviously, the quicker the heart rate, the smaller the PR interval is going to be. Which is why, um, knowing to look up what the normal in travels are in ages is important. So this is gonna be a test on P. R intervals. What do you think is happening here? If you don't know again, Don't worry, because we're gonna learn about it on the next slide. So what does the PR interval look like? Is it short or is it long? Mm. And then won't you think might be happening? You can just randomly choose an answer. It doesn't. It is a matter much. So yes, it was wolf Parkinson White. So well done. I am. For those of you have tears in that. And so the PR interval here was really short. There's basically nearly it's less dinner than one small square space between the P wave on the R wave. The R wave is humped, um, and the reason why the R wave into is humped is because you've got an accessory pathway, which is what wolf Parkinson White is based on, that tries to do its own thing. And and two, the polarize early. Which is why it's so to propagate theoretical impulse early, which is why our wave is slurred. Um, we can yet talk about it again, or mention it again towards the end on the end of the session as you go lower down from the S a note. So the main battery of the heart from the atrium to the ventricles. Um so through all the Y is, at some point, you might have a bundle branch. So a branch of your bundle of hiss, which is the main wire or the represents the main wires that go through the ventricles. You might have abnormalities off of those bundle. Branch is, um I want to go for through the A V note. Um, you might get a block in the 80 or from the main or through the main branches, And if that happens, you might be getting something called a Navy block. And so it's quite, um, difficult to remember which one of which one of them is which, um, the way I remember, they used to sort of, like think about them as and relationships. So if you have a nice relationship and with your friend, you're the P wave. Their the cure s You get along really well. You're really close. But then, once a blockage between your happens, for example, a pandemic and you're not able to see each other, you become more distant. Um, the more distant you become. Um, obviously, the more severe the block is, if it's if it's if it's a first degree A V block, then you don't try to reconsider weight with each other. Nothing happens. You're just distant from each other. Um, if it's a second degree, if it's a mobitz one or a winky back, um, you are distant from each other. You don't try to reconsider a eight um, well, each try of, like, gradually to reconsider e eight until there's nothing left to do on your friendship falls apart. Um um, live. It's time to friendship. Um, where where you don't You don't think anything's wrong between yourselves. All of a sudden, your friend just disappears, and then a further gravy block where you just have your lives separate from each other. So the P waves have no relationship with the ventricles whatsoever. They both depolarizing each other separately. Um, hopefully that hasn't made you more confused about the bundle blocks at all. Um, but we're going to practice that in a second anyway, when it comes to the QRS complex, So the QRS complex represents the electrical charge of the ventricles. Um, it's really important to look at whether that is the cure. Arrest broad is the cure arrest narrow? Um, what does the Curis look like? So what do every single element look like? What this the Q wave look like? Is there a Q away for this? The islet wave look like, what does the S Wave looks like? And on? The very helpful way of thinking about it is, um is the cure is long is there are other always s with stool or deep. Um, And when it comes to the axis, um, the way the easiest way I found in terms of calculating the Axis is looking at D one and a VFC lead one. And Avia, because lead one. If we go back at the beginning. Lead one is the horizontal lead, isn't it? Um, on a V F is the vertical vertical lead, and if united together, you get a 90 degrees angle in order to calculate the axis, I usually look at how positive or how negative each of them are. And then, according to that, um, I imagine myself is having an axis going horizontally fruit for me or for the patient and also vertically on according to whether a V F it's positive or negative or lead one is positive or negative. I've roughly imagine where the axis is going to be. So if it's right and a right axis QRS sort of like in the right in the record drink right to period Cordant left and very quadrant left superior cord runs. And that's usually more or less what you need to know. Knowing the exact number and on a glance isn't the most helpful. The things. So if you're thinking about calculating the curious access or thinking about whether it's negative or positive, um, in my advice, this would be the easiest way of thinking about it. I am, and hopefully these lights will be shared with you. If they're not taking a picture of that circle, that explains where lead one is positive and where it's negative. Same as a V F should hopefully be a bit more helpful. That's what I found really helpful. Yeah, we can upload the slides after the session on tomato. Amazing. Thank you. And in pediatrics, there are some quirks and some things that are normal compared to some things that aunt Normal and adult a CJ's. Um, when it comes to rvh. And you might have or might have not heard the fact that babies are born with a physiological right sided hypertrophy or right ventricular hypertrophy, Which is why you will see an element of rvh, um, on any CJ mm. The most accurate lead to use for right ventricular hypertrophy is usually the one, especially if you think about where V one is placed for your first pack or dio lead him because it's the rightist of the prick or dio leads. It's obviously going to be the most useful. Um, if you've got rvh, therefore, more energy is going to be needed for your right ventricle. Therefore, it's going to be a lot more positive in your rightist of leads, Um, in the first week of life, because you've got a knell Ament of rvh. Um, and upright T wave is going to be normal. Um, but after one week of age, it will be abnormal. Um, the same is, and thinking about your are is our pattern and B one him that again in terms of, um, your first are And your second are, If your second iris taller, then you start then that is abnormal. I am on. Do if you have a pure are wave and V one rather than having a knell Ament of s and that again over six months of age is abnormal. And that's due to the lack in between reversing or just switching from rvh to a normal to a normal AM heart muscle when it comes to your left ventricle. Using Week six is probably the best lead in terms of, um analyzing whether you've got left ventricular hypertrophy or not, because that's the for distal the leftist the leftist of your prick. Order your leads. This is again another reminder of how to You're always and you're s waves. Are they thin or how, How Um um how deep and both in V one on B six per age. Mm. And this is a really good example of hypertrophy. Your are waves aren't meant to go over the baseline or the eyes electric line of the above him of the above lead lead reading. We can't be talking about QRS without, um moving on to the ST segment. So once your heart is charged from electrical point of view, it will have to uncharged at some points it to the polarize. The ST segment is that time in between those two processes, Um, when it comes to pediatrics. Very important, it's to remember, is that unlike adults you can have in pediatrics, you can have ST depressions a normal, um so in a limbo lead ST Depression or elevation of up to one millimeter, um, or two millimeters in the left record, your lead is normal. Um, you can have GI point depression, Um, as long as it's the press without sustained ST Depression on Deacon have benign early reports or is a shin in teenagers where the ST segment is elevated and calm. Caved in leads with an upright T wave, and they sometimes look like half of a smile If you imagine you are always being the nose. Um, and the concavity being half a smile, you can already see that they look like half of smiley face half smiley faces. When it come to ST segments, you're more likely to see you're not so likely to see myocardial infarctions impedes. They're still possible, but really, really rare. However, when it comes to ST I abnormality to more likely to see regarding which is something that you shouldn't be missing, um, these Children will present with histories like collapses. Um oh, you might just find them. Incidentally, when you do any see GI for a totally different reason, I am sorry, Godless of the Burgard A type. Um, if you know to something like this, this is something that you shouldn't be missing, especially with a positive history. Um, we're going to get to some exercises in a minute, but promise will end with the drive. It's, um, soon when it comes to your t wave. So your heart was charged, started d charging or in charging. And now it's uncharged. So repolarization your T wave represents the repolarization process him and what does it look like envy when it's positive in newborns and should reverse by day seven? Um, if not, then it's pathological rvh rather than a physiological rvh. And to please remember that, um, and when it comes to your Q TC, um, sodium terrible between your Q wave and off that your t wave him, you've got the formula on the screen. But there are calculators such a medicine, such as medcal, that can calculate your Q TC for you. Um, as long as you get the Q TC number than it least for the Q TC calculation, then you can look up whether it's normal or abnormal as per age when it comes Infants of less than six months, Um, your QT see should be less than not 0.49 seconds when it comes to the older than six months. So any child older than six months should have a Q TC of less than not 60.44 seconds. And but as long as you remember that, it's different between six months and after six months on, do you know where to look up the calculation or a calculator for the Q TC that's in my opinion or you need to do so. Let's go back to a hoot for a Q TC question. So just, you know, Christian. A few people having issues with the coots. I don't know if it's possible to slow it down, because I think it's there's a slight lag between the two on the presentation. I don't know if that is something that's possible on your own. Um, let me have a local. Don't really think so, cause I did look at that, Um, when I did the Coke West today, to be honest and I don't really think there is Yeah, no, I I honestly did Look at this this morning cause I did think about the 30 seconds being a bit too little. So I do apologize for that. The question will be around. What kin prolong your Q TC myocarditis. Hypocalcemia had injury remind award syndrome, some examples, and you can select as many as you want. It's not a contest or anything, so this is why I'm not really bone. Worry if if there is a like or if you can't answer on time, this is more for everybody's learning. It's no, it's not. It's not the test. So for the purpose of the Q TC and what can cause your key to see to be longer, all of the answers were correct. So from head injury to hypocalcemia myocarditis on Draman award syndrome, mainly because in order to to charge her in charge, you won't need it. Calcium, Your muscles can't function without calcium so low calcium will extend your KT. See, So the charging of of your myocardium myocarditis is obviously information and information within the myocardium. Um, the inflammatory process will affect the electrical charging of your of your myocardium. So therefore, your QT C will be prolonged and with a head injury, you have, um, the same as I CP. Um, your, um automatic automated nervous system automatic nervous system that has a knock on effect when it comes to, um, your myocardium. Um on a reminder, Ward syndrome is again a ready common reason for a prolonged QT. See if present again on q TC. So we've talked about long Q. TC What can make your q TC short? And why is it important to find out whether somebody's got a longer a short Q TC? Because if you have a longer. Short key to see your risk of developing great meals. Um, with the long QT. See you can fix that. So if it's for example, hypocalcemia, you can give calcium. If it's a drug, causing the long Q TC, you can stop the drug. If you can't stop the drug, then you can monitor the Q TC if you've got too short. Q. TC, Um, how hypocalcemia is a reason? If you can fix that, that's great or digital list. If you give somebody digitalis, you can stop it if you can. Um, but unfortunately, if it's something congenital and the rest of your fingers congenital, I'm short key TC. You can't reverse that, so you will have to consider to pacemaker for that. Oh, not necessarily yourselves. But acute. Um, the pacemaker will have to be inserted for that. So, in terms of reasons for prolonged QT, see, we've got hypocalcemia myocarditis, long QT syndrome such as remind award, head injury drugs and hypomagnesemia and Shoki TC. We have the opposite of hypocalcemia, so hypercalcemia digitalis. There's such a fingers. Congenital short Q t syndrome. However, hyper magazine me A doesn't have a nephrectomy the myocardium so hypomagnesemia isn't going to make your q t shorter and the biggest problem when it comes to um what one of the biggest confusions when it comes to looking at any C G is whether something is feet e or SPT Um, And don't worry. Even the biggest um, Mezrich is out there sometimes have a problem when it comes to our pediatric registrars have a problem when it comes to differentiating between 80 and s V. T. As long as you remember the fact that you can look up something called and bird got a criterias, Um, I'll have this table somewhere on your phone That should make it a little bit easier. And something else that will be really helpful is to know that in kids, um, so of over 95% of complex tachycardia Zarah actually a form of sbtc with aberrancy so you it's very unlikely unless there is a reason or specific on the line course that you can think about for a child to have 80 now around that we spoken about whole complex and have thought about a way of reading a CGs. So whenever you read any CG, think about your structure have a structure when it comes to reading the CJ's, start with your P wave and go through your pee. Um, so your p wave your PR interval your QRS your t wave your q TC, um, and your ST on If you if you do that, even if you need five minutes to read on a C G, that should be okay because nobody should be rushing you to read to read any. See, Gee, if it looks like badness and you're really junior, you're obviously expected, or it's okay to ring a senior. Um, for what you should be remembering is that you will be treating the patient in front of you rather than if if it's something acute. Um, so obviously go for your A p l s. Um, But if it's just the c j on the patient is stable. Let's go through some cases. Um, but if you're not sure at the end of today, ask your senior or even call your friendly, very friendly cardiologist him. That's what they always say, because they draw the have somebody ask them for help rather than having you worry, um, somewhere in a day, th talking about dth is Let's move on to, um, some cases now. So we're gonna, um, have CCD uncle who? It in a second. You've got a five year old that's under cardiology. End of DTH. The patient has a history of proximal tachycardia is, um and have been successfully terminated with the dentist seen or vagal maneuvers. So he's come to a hospital before being really tachycardia on. He either had a vagal maneuver organization done, and that seemed to have worked really well. So what is this CCG? And I suppose in a way, they're so shows why context is really important. Yes. So absolutely, that was SPT well done. Don't worry if you didn't know because it's a very, very difficult, easy g to read, and it's really commonly mistaken with BT anyway, Um, but here the context was really important. This was a patient that it had. Tachycardia is in the past that were successfully terminated with the denizen or vehicle maneuvers. We've already spoken that over 95% of patients pediatric patients will have a form of SPT on day after you did vacant when you first either made them blow through through a closed syringe or if it's a baby, literally put ice over their face. That actually works, um, or compressed their eyeballs. What was Their eyes are closed and this is their E C g after vagal maneuvers, and you can see Delta waves. So therefore the patient has or Parkinson white. So how does the ice work? What is it called the baby your child to do? It's so if a child has SPT If you put ice so for their face that activates there in Paris, sympathetic response on it just slows down. It just slows down their heart rate. It doesn't always work, unfortunately, um, but most sometimes it does on gets a very quick thing to do rather than get a cannula. Renan, User down is a If that child is older than you can just give them my syringe that, like a closed syringe that doesn't have any air in it, um doesn't have anything in it, obviously not with a needle at the end. And just make them blow through it of like, for the end. Bit of the syringe, Um, in order to cause to course a vagal, a vagal money, va. So you basically activator Vegas response which will slow down your heart rate. Does that make sense? Yeah. You've probably heard about vagal maneuvers in Sort of like a a less previously when it comes to adults. And, yeah, the syringe one. The ice was I know what a little on his cardio. The people have never seen this before. They usually get freaked out when a baby goes into SBT and the nurses go to the freezer and just bring a bag of ice on day dunk the baby. Either they drunk it or they put, like, some ice over their face, Obviously wrapped in a towel. Yeah. People tend to be a quite freaked out about that. Um, but it it does work. Not always, but it does work. Sometimes it's whatever. Try next case, and this is a really case. Um, this is a 13 year old girl that came in with vomiting, plus plus plus, whilst in any, um, she developed this rhythm. Andre became unconscious, and I suppose it's safe just to think about Is it abroad? Is it a broad pick your s, Is it not? So you're right. It was VT. Unfortunately, um, and the reason why it was VT. If you think about it, is the patient been vomiting? So she developed Selectra an electrolyte abnormality. Um, it wasn't thought to be, um, Beattie in that situation on because the patient wasn't, um treat it accordingly. She unfortunately died. And it was awful to be the one because I saw the I wasn't helpful thing. The case. I was given the siege, and I know it sounds really cooking It shouldn't, but and it's located to know, know how to read any CD in the cute situation, but as long as us connected to somebody or ask somebody. But I think it was really sad to be the one to see the c g during 100 over I am and to kind of my heart just sank. Um, because yeah, um, it could have it could have been treated differently, especially if you know, if you know your, um, algorithms again, why context is really important. The next TCG is going to be about an 11 year old girl. Um, that presents the hospital. And you this's hurry. See? Gee, And what you know is that on her list of medications, she has PPO. What do you think has caused this? If she has e p o your glasses Really interesting, actually, seeing how much the context effects these like, it feels less so in adult medicine, in my opinion, or at least at the level that I work at. Yes. And I think it's still something, you know, that is important. Um, very much like those last three. See? Geez, I would have been an adult said straightaway. Both of them were BT. But then with the added history and stuff Yeah, uh, so the truth here was hyper khalidiya. Um, on it was quite bad. Hyperkalemic, uh, initially, in the initial stage of hyper clean, you you get really, really peaked T waves. Um, but the more hyperkalemic the person is, the more it will inhibit your electrical transmission on the more you're going to swap towards junctional, read them on, then eventually towards VT. So or you will see just really weird Cure s is are really, really broad. Um, in this situation, the QRS is looks really, really broad and doesn't really look like anything. Um, so this is the typical aspect for for hyperkalemic um I mentioned in the quiz something cold and so of, like, sign waves. Sign waves look like sinusoids. So, um, kind of like a rounded dome That is positive. And another round of doing that is negative. And and that happens in potassium. That is, like, nine plus, um, or over nine. Um, depending on how sensitive your heart is on again, that happens because of the more potassium you have. So which, if you think about if you think about it from a biochemical. And, um so it's like by a cellular point of view you have potassium inside your cell rather than outside yourself. Um, so in order to and if if we go back to the initial slide where we have, um, the membrane potential, you will have stadium outside of the membrane and potassium inside the memory. So the the more potassium you have outside the membrane, the more off like the more he polarized the cell is gonna be in, the more the more the more repolarization I was gonna be in, the more you, the polarization will be inhibited. Um, so something to remember when it comes to hyperkalemic. I know it's something that we learn about in my Carina cases in adults but actually can happen and Children as well. Um, again context. So you have a 17 year old that was rescued after falling in a river. And, you know, it's November. So we're jumping in time in November and you get a child that fell into a river. She's usually fits and well oh, all right. Dreamt a different case, um, affect a 14 year old girl who's fit and well and had a road traffic accident. Sorry. And it's something that I mentioned when we spoke about ST ST and Terrible's. Sorry, that was my fault because it was a a swap between my slides on the quiz. So on this E c j u. If you look at it, you can notice the gross thing that jumps to you. Yes, you have P waves. Yes, it is written. Make that you have, um, generalized ST elevation on in this situation because it's a fit and well, girl that's had a road traffic accident in here, you would have had a head injury. So grazed ICP. So probably a bleed, because a raised ICP, like I mentioned earlier, will affect your automatic and never system so that full, Um, the way and the way in which your myocardium, um, so functions. However, I going back to the 17 year old that was rescued after falling over over in November. For those of you that chose Hypo Thermy earlier. Okay, so yeah, absolutely. This was hypothermia. And this finding that you can see on the's this snippet of any CG these lip that little notch after the R wave. And it's called an Osborne wave. Um, you can see it very, very commonly in hypothermia. Say, if you have a patient that, you know, you just get shoved this easy to you in front of you and you're like, Who's deceased CD From on. If somebody says, Oh, it's from that person that was found fallen in the river, you can say, Oh, what's that temperature? Because they might be hypothermic. Um, however you can see it. Azzam Normal variant A swell. This is another example of, um, a head injury. And here you have something called cerebral, um, cerebral waves and re brought T wives. You can see the amplitude that very, very picked, but negative rather than positive and apologies that I've jumped again to the head injury bit him, but they're quite important because you might see them after a traffic accident. But in pediatrics, um, we sent. We have Children that have a VP shunt on their shins can block quite often. They don't always present with a headache or some setting. Um, there was a child that I had during my, um your irritation, who came in with a very non specific headache that had been death of three weeks. Um, your body, it thought the patient was actually blocked. But it was, um she wasn't some setting. She was clinically, really stable on. I bet my life that if we don't uneasiness something, know it's dramatic. But something similar would have would have, would have been on it and last e c g of the quiz. And then there's gonna be one of the question. So you have a 15 year olds that presents with chest pain, has absolutely no past medical history. She comes to the ward walking chatty. What do you think has happened here? Absolutely. Say well done. For those of you, this shows and lead miss much. Um, it's really, really well, it can happen. It's happened to me while style was one of my rotations. Basically, if the child looks really well, depending obviously on the description of their chest pain, one thing that could have happened is for the lead to be mismatched. And the way you you think about that versus extracardiac. Because the P wave is negative. Um, in some instances, is that, um you have, um, cable or vessel, um, sale in terms of you might see a different progression from the one to V six, and that's only one example, but And as you can see and lead one, unlike Dextrocardia, um, your T wave is negative here, Um, which is something that you would have wouldn't have otherwise. Um, seen in an extra card yet? So something to always think about again. Thinking about the context. Who was that ACG off on? What did it show? The way I was referred, the child was Oh, I've got a teenager and she's got chest pain on. Do the EKG is really abnormal. So I panicked and we got the child up and she walked in as if nothing was happening. She was really weak. She was actually really well, the pain had gone. I was showing the CJ I was actually really good, too, because it took us, like coughing out to get another EKG done. Um, so be really careful when you get an e c g thrown on. Do if you're not the person performing it, if you see that, um, make sure to to think about whether there is the option that the leads were inverted. That being said, I was really naughty when I was left to because, um basically I had a repair that was really, really worried about on psychiatry. Um, she had on on recordable temperature. Um, Andi, we tried referring the patient. Basically the well, I think my Reg tried referring the patient she was refused on to get her sent to hospital quicker. I've reversed the leads myself and hopes that nobody would notice until she got to eat a him. And nobody did notice until she got to a day on there. She was admitted for over a week with the naked eye or three. I am on all the drama him, But never do that. Onda Last but not least, if I went and out. If you're worried whether you're a reg hip. Whether you're consultant, whether you're a junior over more junior and s h o, Please call your friendly pediatric audiologist or senior because you're never alone. If there's something that you're worried about and you're just not sure what it is him seek advice from from someone that does this on a day to day basis and the pizza called. Yet registrars will usually pass, um 80 j past the consultant. Um, so don't be worried, honestly, but there will be somebody to help. They are really useful. If you recognize the gross features on, Do you know what you know Sort of know what you're looking for if you have a structure in your head. But if you get lost because like I said, STD's can be Pandora's box is there will be somebody there to help you. Don't forget the day exist. They might be in a tertiary center. They might be busy. They might not give you an answer straight away, but long as the child is stable, um, please seek help because help will be that they're all really there might be grumpy sometimes, but most of the ones I've met were friendly I am. And thank you so much. Thank you for joining. Please, if you have questions, ask them in the trap bar. If if I can't answer the questions. Um, hopefully after going through a short recap, you feel a little bit more confident when it comes to easy days. If you've never ready CDs before, hopefully this has given you a little bit of a boost of confidence to get the shot of the slides will be shared with the, um, on D that the recording will be available. Um, you know, we watch it any time we can message me if if needed. Um, my twin, my twitter, um, addressed was shared, um, into into the event. And actually, I can write it down. Here I am. Everybody uses life in the fast lane, please. His life in the past, lane. If you're curious, if you want to read more, it's one of my favorite websites to just dive into and just get lost, cause it's endless when it comes to a C G. Um, sed knowledge. Um, and the second website was just something that I used for for some of the pictures. Excellent. Thank you, Christine. Yeah, there's There's so much I'm definitely going to go back and re watch that we're going much. Well, I didn't know how much I've gotten since I started. Perhaps a little universe, like, literally. I I don't know what made me just like a CD so much. I used to not like them when I was a student. And somehow, once, it made more sense. Um, because when I see any seizure, I imagine the heart three day and just the electrical enforce is going through the heart. Um, I and it's so quick on, but yeah, I I hope I've kind of passed on the passion or least the interest, because they can be quite dry. No, I was really useful unless people saying thank you in the chat. I'm looking for any specific questions. As Cristina say, we will put all the recordings and slides up on metal on late. It only takes me a few days to get onto YouTube. Um, I know there was one question earlier which I think you may have touched on. That was from So you were, um, just going over how head injuries caused the prolonged Q TC. So in terms of again your autonomic nervous system damaging your myocardium. Unfortunately, um, that's more or less the length of the physiopathology that I can I can explain. Um, but it's your arm or genomic nervous system that is at fault for that. So you raised ICP secondary to your potential hemorrhage. Secondary to the injury. I hope that answers your question. I've also posted a link to the feedback form. Once you fill that in, you get a excuse me, a certificate of attendance. I can see that a lot. I said thanks. I understand it. Appreciate that I've also dropped the same links in Facebook group. Uh, and also your email inboxes. Thank you. I also got a tiny curiosity before everybody leaves Winky back can be normal when I Children or people are asleep. I had to, um, do my piece carpet rotation to find out. No, again. Because of sort of, um, parent Paris in Pathetic. So are sympathetic parasympathetic system. Um, that kind of a cares outside of your artery and sleep. Small curiosity. How did you find out? Was it just that the CT was done on someone that was asleep? Way had a patient that had cardiac surgery, How they're pacing wise out on. For some reason, they were still monitored while they were asleep the second day after the wires were removed. I was like, Sure, this is the There's called me. She was like, um, this person is in in a form of arrhythmia. Can you come and do an ACG on them? Um, because you obviously only see later on and on the monitor. So I came. I did that. I was like, Oh, this is winking back. This is really cute. Um, so message. I'm bringing my right. And I was like, Look, is this something that I should be worried about? Like Mick, that is absolutely fine. It's very unlikely. Related as long, obviously is the child's find was nicely comfortable in the sleep and reactive. Um, it's fine. I was like, Oh, okay, literally. Nobody in the cardiac department gets excited about Winky fact when people are asleep long as it normalizes when they're awake or not so interesting. Okay, well, I can't see any questions coming in. Thanks very much. Please do fill out the feedback forms we do read them is really useful for us to improve things on. Also, it's useful for Christine. Right? Evidence? Excuse my small dog barking at birds outside the house. Um, well, there is a question from doing. Can you see that? Pristina? Yes, on and looking to Sure. Small thing from that's going to show my screen. But, um, say if you think about lead V one and lead V two, they're the most the leads that are on the right hand side of your check. Well, so I let it sort of especially the one on the right side of your chest. So if you think about your reporting or is a shin and when that occurs, what would bring the way of the report? Or is a shin wave towards the right hand side, um, of your heart So you can think about rvh Say, think about, um, you have physiological rvh up until more last day seven because of your feet or circulation. But if after they seven you don't have your T wave doesn't flattened or become negative, then you would be thinking about pathological rvh. If you're, um t wave is positive in V one plus minus for you too. The reason why I show. That was like, because I'm not I'm a visual purse. And I learned if I see someone face talking at May, I usually don't remember anything. No, definite. Was you literally him. To you? It was positive. Just below seven days of age. Oh, should be. Could be if you've got rvh. Okay, well, I think we'll wrap things up there, so thank you very much for a 10 day. Thank you, Christina. One for presentation. Um, it was actually I will be posting on Facebook. Your email inboxes, whatever with details of our next session. Enjoy your evening, okay?