The document discusses ECG interpretations for various cardiac arrhythmias, particularly for intensive care scenarios involving ventricular tachycardia (VT), atrial fibrillation, and Wolff-Parkinson-White syndrome. It highlights essential diagnostic criteria, treatment options, and case studies for understanding and managing these conditions in patients with differing presentations and histories. Additionally, it outlines important rules and recommendations for handling arrhythmia cases efficiently.

1. KHALED FAROUK; MD
A. PROFESSOR OF CRITICAL CARE MEDICINE
CAIRO UNIVERSITY
ECG for intensivests

2. A Story ?
You always need a story
When exactly in the timeline of your patient you
intersect?
Dose this changes his/her life?
More life or life no More

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Asystole

4. V. FIB

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T.D.P

7. T.D.P

9. WCT

10. Wide Complex tachycardia

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Differentiating ventricular tachycardia
from svt with aberrancy
➢ Leads to correct initial therapy
➢ Avoids use of Verapamil which may precipitate
hemodynamic collapse with V.T.
Cannot use rate or the presence or absence of
symptoms as discriminator !
➢ Use ECG criteria for diagnosis
➢ Use presence of risk factors for V.T. as discriminator

12. What is WCT criteria is addressing?
I. A -V relationship
dissociation,
fusion, and
capture
II. Axis twist
North west,
LBBB+RAD, and
RBBB+LAD
III. Morphology criteria …
Brugada
Concordance
Four leads concept

13. The Brugada Criteria

14. Morphology Criteria for VT

15. Four Negative Leads Concept
Farouk.K EHJ, 1999
The presence of predominantly negative QRS complex (QS,
rS) in two out of four leads (LI, LII, V1 and V6)provided
that LI or V6 is included…..diagnose VT (sp. 100% sen.
86%).
Otherwise consider SVT with aberration or antidromic
tachycardia.

16. WCT
Look at LI and V6
-ve +ve
VT Look at V1
-ve +ve
VT SVT with aberration
L1 and V6 -ve L1 or V6 -ve L1 and V6 +ve
VT SVT
Look at
LII

17. Other ECG Criteria
B.Axis twist
➢ North - west QRS axis deviation
➢ RBBB morphology with LAD > - 300
➢ LBBB morphology with RAD > + 900
C. A_V relationship
➢ Fusion beats, capture beats
➢ Ventriculoatrial conduction with block
➢ Previous ECG show MI or previous ECG show that during
sinus rhythm, bifascular block is present, which changes in
configuration during tachycardia

20. Ventricular Tachycardia Concordance
(different from “concordance” as used for ST-T vs QRS)
Step 1: Absence of RS in all precordial leads

21. Step 1: there is no absence of RS in all precordial leads (no concordance) (V5, V6)
Step 2: RS in V5 > 0.10 ms, therefore v tach
Step 3: No AV dissociation
Step 4: RBBB pattern (tall R in V1). Notching of this monophasic R indicates VT

22. Case 1
A 67 year old male with history of previous infarct and reduced LV
function presents with palpitations and dizziness.
His blood pressure is 80/40.
A. Synchronized cardioversion for VT
B. I.V. Procainamide for Atrial Fibrillation with WPW
syndrome
C. Synchronized cardioversion for unstable SVT with
aberrancy.
D. I.V. Amiodarone for SVT with aberrancy in a patient
with reduced LV function.

24. ➢ This patient has ventricular tachycardia.
➢ An RS interval of greater than 100 msec is clearly
visible.
➢ In addition, by history this patient is overwhelmingly
likely to present with VT with a wide complex rhythm.
➢ Also this patient is not stable with relative hypotension
requiring immediate cardioversion as opposed to
pharmacologic therapy.
Answer A

26. Concordance and Northwest Axis

27. Case 2
A 42 year old smoker presents to the ED with palpitations.
His blood pressure is 100/60.
The following rhythm strip is obtained.
A. Emergent cardioversion for polymorphic VT.
B. I.V. procainamide
C. I.V. lidocaine
D. Diltiazem drip to obtain rate control.

28. What Is It ?

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Answer B
➢ This patient has WPW with atrial fibrillation and
a rapid ventricular response.
➢ He is stable, thus I.V. procainamide is indicated
to slow conduction down the accessory pathway.
➢ Diltiazem is contraindicated.
➢ Lidocaine will have no effect, as this is not VT.

30. WPW syndrome

31. Case 3
A previously healthy 15-year old boy presents to ED with
sudden onset of palpitations while playing sport. On arrival
to ED he is alert and pain free with a good blood pressure.
His ECG is shown below:

33. Antidromic tachycardia
• This ECG is an example of antidromic AVRT secondary to Wolff-
Parksinson-White syndrome
• Electrophysiology testing confirmed pre-excitation with a right-
sided accessory pathway (Type B WPW). Echocardiography
revealed a structurally normal heart. He was discharged home on
oral flecainide pending ablation of his accessory pathway.

35. Case 3
29 year old Female
Hx
Presented to the ER after 3 episodes of palpitations over 3 days,
and a feeling of impending doom
Hx of sudden cardiac death in uncle at age 45
No hx of syncope
PMHx
Healthy
Meds
No medications

36. Brugada syndrome

37. Brugada syndrome
• Described by Brugada and Pedro 1992
• Frequent cause of death in pt. with normal hearts
• Also a cause of sudden death in athletic population
• More frequently diagnosed in males of South East Asian
descent
• Characterized by ECG abnormalities in V1 to V3:
• i ) incomplete RBBB
• ii) ST segment elevation

38. Brugada syndrome
• Caused by a reduction of sodium current across cardiac sodium
channels
• ST elevation thought to be due to rebalancing of currents active at
end of phase 1
• Definitive treatment is by placement of Internal Cardio-
defibrilator(ICD )
• Mortality at 10yrs is 0%for ICD and 26% for pharmocological
agents(amiodorone,B-blockers )

39. • Pseudo-
RBBB
(but no
slurred S in
V6)
• ST
Elevation
V1-V3
• T wave
inversion
= Brugada
Syndrome
ECG

40. Summary
• Think of Brugada syndrome in a patient with palpitations
or syncope!
• Pseudo-RBBB
• ST Elevation V1-V3
• Family history of sudden cardiac death
• Send patients with suspicious ECGs to cardiology /
electrophysiology for drug challenge or electrophysiology
testing.

41. Case 4
• 52 yr old man
• No Hx of IHD
• Known HPT on Rx
• Presents with acute onset chest
• Initial ECG normal
• Cardiac enzymes normal
• Admitted for observations

42. Wellens syndrome: note the biphasic T waves (positive-negative) in leads V2-V4. Upper
arrow points at the positive deflection, negative arrow points at the negative deflection.

43. Wellens syndrome: note the deeply negative T wave (>5 mm) in V2-V4. We also
have the biphasic shape in lead V2. ST segment is

44. Coronary angiogram

45. Case 5
• A 30-year old female with a history of Conn’s syndrome
secondary to bilateral adrenal adenomas presents with
generalised weakness and muscle pains after a change in
her medications.

47. Hypokalemia
The ECG shows:
1. Sinus rhythm at around 70 bpm
2. Normal axis
3. PR interval 200ms (upper limit of normal)
4. Long QT (640ms, QTc 700ms)
5. Widespread downsloping ST depression / T wave
inversion
6. Prominent U waves, especially in the precordial leads

48. HARM NO ONE
Rule number one

49. Rule 1
• If you don’t have time shock or pace no more peace.
• Most of the time you have good time, you are in peace.

50. Rule number two
• Look at the toe

51. Rule 2
• Time is perfusion and flow don’t leave it low

52. Rule number three
• Master the key

53. Rule 3
Key may be:
Hx.
C/P
Criteria
Own records

54. Rule number four
• Never shut the door

55. Rule 4
• Arrhythmia patients are frequent comer and may
come late don’t use your hummer.
• Record your experience, send a free advice to your
college next visit, let him start where you finish .

56. Rule number five
• Search the wife

57. Rule 5
Salt :
Low salt brings insult.
Excess K+ is not ok.
Fat :
Excess fat is always bad.
Young widows are always sad.

58. Rule number six
• Use the tricks

59. Rule 6
C.S.M
Valsalva
Leg up
Fluids
Vasopressor
RT chest leads
Pacing
Echo Probe
Ask questions
Make the call

60. Rule number seven
• All and above ask the haven