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ECG: Wide Complex Tachycardia
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  • 1. K.M.JEYABALAJI Dr.P. VIJAYARAGAVAN’S UNIT
  • 2. HISTORY
    • A 22 yr male patient came with complaints of
      • Acute onset breathlessness
      • Palpitation
      • Profuse sweating
      • Vague chest discomfort
        • For past 1 hour
  • 3. EXAMINATION
      • Dyspnoeic, tachypnoeic,
      • Pulse- 180/ min REGULAR
      • BP- 90/ 60 mmhg
      • JVP- ---
      • CVS- s1,s2 heard
      • RS – NVBS
      • P/A- soft
      • CNS- NFND
  • 4. ADMISSION ECG
  • 5. CHEST LEADS
  • 6. FINDINGS
    • TACHYCARDIA
    • REGULAR RHYTM
    • RATE- 200/min
    • AXIS – EXTREME NORTH ( northwest)
    • WIDE QRS COMPLEX
    • RBBB PATTERN IN V1
  • 7. DD FOR WIDE COMPLEX TACHYCARDIA
    • Ventricular tachycardia (VT)
    • Supraventricular tachycardia (SVT) with Aberrancy
    • SVT with drug or electrolyte induced QRS widening
  • 8. APPROACH WIDE COMPLEX TACHYCARDIA REGULAR/IRREGULAR AV DISSOCIATION CLASSICAL BUNDLE BRANCH MORPHOLOGY BRUGADA CRITERIA AVR CRITERIA
  • 9. BRUGADA CRITERIA YES Absence of RS complex in V1 – V6 VT RS complex duration > 100 ms VT AV dissociation VT Morphology criteria VT
  • 10. BRUGADA CRITERIA
  • 11. MORPHOLOGY CRITERIA
    • For RBBB-type complexes
    • Is there an rSR’ morphology in V1?
    • Is there an RS complex in V6 (small
    • septal q OK)?
    • Is the R/S ratio in V6 > 1?
    • For LBBB-type complexes
    • Is there an rS or QS complex in V1 and V2?
    • Is the onset of the QRS to the nadir of the S in V1 < 70 ms?
    • Is there an R wave in lead V6 without a
    • Q?
  • 12. AVR CRITERIA
    • Presence of an initial R wave
    • Width of an initial r or q wave >40 ms,
    • Notching on the initial downstroke of a predominantly negative QRS complex
    • Ventricular activation–velocity ratio (v i /v t ), the vertical excursion (in millivolts) recorded during the initial (v i ) and terminal (v t ) 40 ms of the QRS complex. When any of criteria 1 to 3 was present, VT was diagnosed; when absent, the next criterion was analyzed. In step 4, v i /v t >1 suggested SVT, and v i /v t ≤1 suggested VT.
  • 13.  
  • 14. VENTRICULAR TACHYCARDIA
    • Absence of typical RBBB or LBBB morphology
    • Extreme axis deviation (“northwest axis”)
    • Very broad complexes (>160ms)
    • AV dissociation (P and QRS complexes at different rates)
    • Capture beats — occur when the sinoatrial node transiently ‘captures’ the ventricles, in the midst of AV dissociation, to produce a QRS complex of normal duration.
    • Fusion beats — occur when a sinus and ventricular beat coincides to produce a hybrid complex.
  • 15.
    • Positive or negative concordance throughout the chest leads, i.e. leads V1-6 show entirely positive (R) or entirely negative (QS) complexes, with no RS complexes seen.
    • Brugada’s sign –  The distance from the onset of the QRS complex to the nadir of the S-wave is > 100ms
    • Josephson’s sign  – Notching near the nadir of the S-wave
  • 16. VT CAPTURE BEAT FUSION BEAT BRUGADA SIGN , JOSEPHSON SIGN
  • 17.
    • NEGATIVE CONCORDANCE POSITIVE CONCORDANCE
  • 18. SVT WITH ABBERANCY
    • • Any SVT can be conducted with aberrancy:
    • – Sinus Tachycardia
    • – Atrial tachycardia
    • – Atrial flutter
    • – Atrioventricular nodal reentrant tachycardia (AVNRT)
    • – Junctional Tachycardia
    • – Orthodromic Atrioventricular Reentrant Tachycardia
    • (AVRT)
  • 19. VT AGAINST VT
    • Northwest axis
    • Pseudo RBBB morphology
    • BRUGADA CRITERIA
    • AVR CRITERIA
    • Very broad QRS complex
    • > 160 ms
    • Hemodynamically stable
    • No previous MI, CM
    • Vi/Vt > 1
    • No fusion, capture beat.
    • no concordance
  • 20. FASCICULAR VT
    • SUPERIOR AXIS
    • PSEUDO RBBB MORPHOLOGY
    • HEMODYNAMICALLY STABLE
  • 21. TAKE HOME MESSAGE
    • No criteria is 100% sensitive nor specific
    • Never go blindly by ECG
    • Give equal imortance to history, clinical presentation,
    • Vitals
    • If you are 100% sure that it is SVT, then proceed.
    • Having even 1% doubt, then treat it as VT
  • 22. THANK YOU

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