K.M.JEYABALAJIDr.P. VIJAYARAGAVAN’S UNIT
HISTORY A 22 yr male patient came with complaints of   Acute onset breathlessness   Palpitation   Profuse sweating   ...
EXAMINATION Dyspnoeic, tachypnoeic, Pulse- 180/ min REGULAR BP- 90/ 60 mmhg JVP- --- CVS- s1,s2 heard RS – NVBS P/A...
ADMISSION ECG
CHEST LEADS
FINDINGS TACHYCARDIA REGULAR RHYTM RATE- 200/min AXIS – EXTREME NORTH ( northwest) WIDE QRS COMPLEX RBBB PATTERN IN V1
DD FOR WIDE COMPLEX        TACHYCARDIA• Ventricular tachycardia (VT)• Supraventricular tachycardia    (SVT) with Aberrancy...
APPROACH     WIDE COMPLEX TACHYCARDIA        REGULAR/IRREGULAR          AV DISSOCIATIONCLASSICAL BUNDLE BRANCH MORPHOLOGY ...
BRUGADA CRITERIA                                   YESAbsence of RS complex in V1 – V6   VTRS complex duration > 100 ms   ...
BRUGADA CRITERIA
MORPHOLOGY CRITERIAFor RBBB-type complexes      Is there an rSR’ morphology in V1?      Is there an RS complex in V6 (smal...
AVR CRITERIA Presence of an initial R wave Width of an initial r or q wave >40 ms, Notching on the initial downstroke o...
VENTRICULAR TACHYCARDIA Absence of typical RBBB or LBBB morphology Extreme axis deviation (“northwest axis”) Very broad...
 Positive or negative concordance throughout the chest  leads, i.e. leads V1-6 show entirely positive (R) or  entirely ne...
VTCAPTURE BEAT                         FUSION BEAT               BRUGADA SIGN , JOSEPHSON SIGN
NEGATIVE CONCORDANCE POSITIVE CONCORDANCE
SVT WITH ABBERANCY • Any SVT can be conducted with aberrancy: – Sinus Tachycardia – Atrial tachycardia – Atrial flutter –...
VT                   AGAINST VT Northwest axis            Hemodynamically stable Pseudo RBBB               No previous...
FASCICULAR VT      SUPERIOR AXIS PSEUDO RBBB MORPHOLOGY HEMODYNAMICALLY STABLE
TAKE HOME MESSAGE No criteria is 100% sensitive nor specific Never go blindly by ECG Give equal imortance to history, c...
THANK YOU
Broad complex tachycardia
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Broad complex tachycardia

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Broad complex tachycardia

  1. 1. K.M.JEYABALAJIDr.P. VIJAYARAGAVAN’S UNIT
  2. 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. 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. 4. ADMISSION ECG
  5. 5. CHEST LEADS
  6. 6. FINDINGS TACHYCARDIA REGULAR RHYTM RATE- 200/min AXIS – EXTREME NORTH ( northwest) WIDE QRS COMPLEX RBBB PATTERN IN V1
  7. 7. DD FOR WIDE COMPLEX TACHYCARDIA• Ventricular tachycardia (VT)• Supraventricular tachycardia (SVT) with Aberrancy• SVT with drug or electrolyte induced QRS widening
  8. 8. APPROACH WIDE COMPLEX TACHYCARDIA REGULAR/IRREGULAR AV DISSOCIATIONCLASSICAL BUNDLE BRANCH MORPHOLOGY BRUGADA CRITERIA AVR CRITERIA
  9. 9. BRUGADA CRITERIA YESAbsence of RS complex in V1 – V6 VTRS complex duration > 100 ms VTAV dissociation VTMorphology criteria VT
  10. 10. BRUGADA CRITERIA
  11. 11. MORPHOLOGY CRITERIAFor 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. 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 (vi/vt), the vertical excursion (in millivolts) recorded during the initial (vi) and terminal (vt) 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, vi/vt >1 suggested SVT, and vi/vt ≤1 suggested VT.
  13. 13. 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.
  14. 14.  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
  15. 15. VTCAPTURE BEAT FUSION BEAT BRUGADA SIGN , JOSEPHSON SIGN
  16. 16. NEGATIVE CONCORDANCE POSITIVE CONCORDANCE
  17. 17. 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)
  18. 18. VT AGAINST VT Northwest axis  Hemodynamically stable Pseudo RBBB  No previous MI, CM morphology  Vi/Vt > 1 BRUGADA CRITERIA  No fusion, capture beat. AVR CRITERIA  no concordance Very broad QRS complex > 160 ms
  19. 19. FASCICULAR VT  SUPERIOR AXIS PSEUDO RBBB MORPHOLOGY HEMODYNAMICALLY STABLE
  20. 20. 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
  21. 21. THANK YOU

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