1. Irregular narrow complex tachycardia with no discernible P waves. Diagnosis is atrial fibrillation.
2. Regular narrow complex tachycardia with short RP intervals and variable relationship between P waves and QRS complexes. Diagnosis is AV nodal reentrant tachycardia (AVNRT).
3. Regular narrow complex tachycardia with sawtooth flutter waves and 2:1 conduction. Diagnosis is atrial flutter.
The following powerpoint presentation is about the current AF guidelines, prepared by Dr Jawad Siraj, who is a final year resident as Cardiology Unit, PGMI, LRH, Peshawar
The following powerpoint presentation is about the current AF guidelines, prepared by Dr Jawad Siraj, who is a final year resident as Cardiology Unit, PGMI, LRH, Peshawar
Echocardiography was performed using contrast for all studies. The contrast agent used was a commercially available sulfur hexafluoride microbubble preparation, SonoVue (Bracco Imaging SpA). This agent was administered in 0.3-mL bolus doses intravenously for each image acquisition followed by 1 to 2 mL of saline flush. After acquisition of resting images to exclude significant valvular disease, intravenous dobutamine was infused at a starting dose of 10 µg·kg–1·min–1 followed by increasing doses of 20 µg·kg–1·min–1, 30 µg·kg–1·min–1, up to a maximum of 40 µg·kg–1·min–1 in 3-minute stages. Intravenous atropine was administered in 300-μg boluses up to a maximum of 1200 μg for those patients not achieving 85% of the predicted maximal heart rate. Images were taken in the apical 2-chamber, 3-chamber, 4-chamber, and parasternal short-axis views at baseline, low-dose stress, high-dose stress, and recovery
Echocardiography was performed using contrast for all studies. The contrast agent used was a commercially available sulfur hexafluoride microbubble preparation, SonoVue (Bracco Imaging SpA). This agent was administered in 0.3-mL bolus doses intravenously for each image acquisition followed by 1 to 2 mL of saline flush. After acquisition of resting images to exclude significant valvular disease, intravenous dobutamine was infused at a starting dose of 10 µg·kg–1·min–1 followed by increasing doses of 20 µg·kg–1·min–1, 30 µg·kg–1·min–1, up to a maximum of 40 µg·kg–1·min–1 in 3-minute stages. Intravenous atropine was administered in 300-μg boluses up to a maximum of 1200 μg for those patients not achieving 85% of the predicted maximal heart rate. Images were taken in the apical 2-chamber, 3-chamber, 4-chamber, and parasternal short-axis views at baseline, low-dose stress, high-dose stress, and recovery
Its a medical presentation describing how to approach to various cardiac arrhythmias in systematic way. Illustrated with more ECG photographs from standard sources.
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The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
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Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
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The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
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Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
6. Reentry
• Requires the presence
of two pathways
– One slow, the other fast
– Unidirectional block in
one of the pathways
– Slow conduction down
the unblocked pathway
allowing the other
pathway to recover and
maintain the circuit
10. Atrial Fibrillation
• Irregular Narrow Complex Tachycardia
• The commonest sustained arrhythmia
• Absence of P waves
• Atrial activity appears as irregular baseline or f
(fibrillatory) waves
• Usual ventricular rate 100-180 in the absence of
therapy
• If HR < 100 without medical treatment suspect
underlying conductive tissue disease
11. Types
• Paroxysmal
– self-terminating episodes that generally last <7 days
(most <24 hours)
• Persistent
– generally lasts >7 days and often requires electrical or
pharmacologic cardioversion.
• Permanent
– failed cardioversion or when further attempts to
terminate the arrhythmia are deemed futile.
Hurst's the Heart, 12th Edition
12. Causes
• Ischemic Heart Disease
• Hypertensive Heart Disease
• Other organic heart disease/cardiomyopathy
• Mitral Valve disease
• ASD
• WPW
• Lung Disorders (Acute e.g. PE, Chronic e.g. COPD)
• Post Surgical e.g. CABG
• Thyrotoxicosis
• Alcohol
14. Multifocal Atrial Tachycardia
(MAT)
• Irregular Narrow Complex Tachycardia
• >= 3 P wave morphologies
• Varying PP, PR, RR intervals
• P waves may be blocked
• P waves may conduct with aberrancy
• Unstable rhythm usually progresses to atrial
fibrillation
16. Management
• Treatment of the underlying cause
• Correction of electrolytes (K, Mg)
• AV nodal blocking agents
• Anticoagulation depending on stroke risk
17. Regular
Narrow Complex Tachycardia
No P Waves
AV nodal Reentry
tachycardia, AVNRT
Irregular
P Waves present
Identify P wave morphology/rate
Relationship between P and QRS
Identify RP interval
19. AVNRT
• Regular Narrow Complex Tachycardia
• Usual rate 150-250
• Abrupt onset and offset
• Variable relation to P wave
– P wave buried in the QRS
– Short RP interval
– Atypical AVNRT Long RP
• Usually no underlying heart disease
22. Regular
Narrow Complex Tachycardia
No P Waves
Irregular
P Waves present
Identify P wave morphology/rate
Relationship between P and QRS
Identify RP interval
23. RP Interval
• Distance from the R wave to the NEXT P wave
• Short if RP interval < ½ RR interval
• Long if RP interval > ½ RR interval
26. Regular Narrow Complex Tachycardia
No P Waves P Waves present
P wave morphology
Atrial rate
Relationship between
P and QRS
RP interval
Atrial rate >200
Flutter waves
Atrial Flutter
Short RP
Abnormal P wave
Atrial tachycardia
With AV delay
Long RP interval
Abnormal P wave
Atrial tachycardia
Short RP
Retrograde P wave
AVNRT, AVRT
Long RP interval
Retrograde P wave
Atypical AVNRT
27. Definition of normal P
• Duration 0.08 to 0.11 (2-3 small squares)
• Axis (0-75)
• Upright in II, III, aVF
• Upright/biphasic in III, aVL, V1, V2
• Amplitude <2.5mm in II (2.5 small squares)
• Amplitude in V1 positive <1.5mm (1.5 small sq)
negative <1mm (1 small sq)
• PR interval 0.12 – 0.2 (3-5 small squares)
30. Atrial Flutter
• Regular Narrow Complex Tachycardia
• F waves conducting ~ 300/min
• Usually 2:1 block with a ventricular response
of 150/min
• Same causes as atrial fibrillation
• No baseline in II, III, aVF
• Discrete P waves in V1
31. Mechanism of Atrial Flutter
• Typical F waves inverted
F waves in II, III, aVF
Page1
EID:34EDT:09:0811-SEP-2009ORDER:
32. Management
• Similar to atrial fibrillation
– Requires anticoagulation
• More Difficult to control rate with medical
treatment compared to atrial fibrillation
• Usually requires DC Cardioversion
• Radiofrequency ablation highly successful in
restoration and maintenance of sinus rhythm
34. Atrial tachycardia
• Atrial rate is 100-240 i.e. slower than atrial flutter
• Usually 1:1 conduction without medical
treatment
• Not terminated by vagal maneuvers
• Mechanism
– Intra atrial reentry
– Automatic – ectopic focus
– triggered
35. Management
• AV nodal blocking agents
• Some are amenable to Radiofrequency
ablation
37. Problem 1
• 68 year old Nigerian male with PMH of HTN,
DM comes to Cardiology clinic for a routine
check up
• He takes metoprolol in addition to Lisinopril
for Blood Pressure Control
• HR 70/min, irregular, BP 150/70
39. Problem 2
• 62 year old female with known ESRD on HD
via left AV fistula developed sudden onset of
palpitations during dialysis; feels her HR racing
• HR 170/min, BP 130/80
• Clinical Examination revealed rapid regular
heart beat, mild LE edema, left AV fistula
41. Problem 3
• 59 year old African American Male, with DM,
HTN, Obesity presents to his internist with
two weeks history of shortness of breath on
exertion
• HR 140/min, BP 140/90
• JVP difficult to assess due to obesity
• Chest clear, mild LE edema (unchanged
according to patient)
42. • Regularity of rhythm
• P wave present or absent
• RP interval
• P wave morphology/rate
• Relationship between P and QRS
Atrial
Flutter
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
ID:00034559908-APR-200903:24:28COOKCOUNTYHOSPITAL
***AgeandgenderspecificECGanalysis***
Sinustachycardia
Leftposteriorfascicularblock
CannotruleoutInferiorinfarct(citedonorbefore18-APR-2008)
Anteriorinfarct(citedonorbefore02-DEC-2007)
WhencomparedwithECGof20-DEC-200813:44,
Significantchangeshaveoccurred
ConfirmedbyKELLYMD,RUSSELL,F(1006),editorJAMES,MAMIE(34)on16-Apr-200915:20:27
D12SL233CID:1
Referredby:ConfirmedBy:RUSSELL,FKELLYMD
BPM153ent.rate
ms208Rinterval
ms84RSduration
msT/QTc306/488
59141*R-Taxes
TEPHANBARBER
162456
Page1of1
EID:34EDT:15:2016-APR-2009ORDER:ACCOUNT:000221162456
43. Problem 4
• 74 year old African American Female with
remote history of ASD repair and Pulmonary
Hypertension comes for follow up
• She takes metoprolol for hypertension
• HR 80/min, BP 120/70
46. • Regularity of rhythm
• P wave present or absent
• RP interval
• P wave morphology/rate
• Relationship between P and QRS
Atrial
Fibrillation
47. Problem 6
• 54 year old White Male with PMH of a known
arrhythmia comes for routine follow up
• He takes metoprolol XL 200mg once daily
• HR 110/min, irregular, BP 130/70
53. Problem 9
• 61 year old Hispanic female with no PMH,
presents to the Emergency Room with fatigue,
loss of weight, palpitations, and feeling warm
all the time.
• HR 200/min, BP 120/80
55. Problem 10
• 48 year old male with severe obesity, a
chronic skin disorder, and chronic LE edema is
sent to hospital from this primary care doctor
after he finds his HR to be very fast
• HR 141/min, BP 130/70
• In the ER an ECG was performed
• Due to concerns for Pulmonary Embolism (PE),
a CT Pulmonary Angiogram was performed
and was reported as negative for PE
56. • Regularity of rhythm
• P wave present or absent
• RP interval
• P wave morphology/rate
• Relationship between P and QRS
Atrial
Tachycardia
57. • Diagnosed with probable ectopic atrial
tachycardia
• No response to IV adenosine
• No response to IV esmolol
• NO response to IV amiodarone
• Started becoming more breathless
58. • Performed DC Cardioversion 50J Biphasic, then 200
with no response
• At second attempt at DC Cardioversion 200J reverted
to Sinus rhythm
Narrow Complex tachycardia Estimate HR
Calculate HR in irregular rhythm, multiply by10 the number of complexes in a 6 second interval
11x10=110
No P waves Atrial Fibrillation
Narrow Complex tachycardia Estimate HR
Calculate HR in irregular rhythm, multiply by10 the number of complexes in a 6 second interval
10x10=100
Identify P waves, variable P wave morphology, variable PP, variable PR intervals
No P waves Atrial Fibrillation
Narrow Complex Tachycardia
P wave are buried in the QRS complex so cannot be seen on a surface ECG
Narrow complex tachycardia Regular, Rate of 190 No P waves
P wave are buried in the QRS complex so cannot be seen on a surface ECG
Regular Narrow Complex Tachycardia, ~140/min, short RP, retrograde P wave
Narrow complex tachycardia, Regular, 150/min, two P waves to every QRS complex at 300/min,
Regular Narrow Complex tachycardia, Long RP, abnormal P wave (biphasic in II, inverted in aVF, upright in III)
Re entry underlying heart disease, specturem A fib/flutter, 90-120, 2:1 block, Ablation 75% success
Crista terminalis, base of pulmonary vein, ablation if incessant
HR 90/min, irregular, narrow complex tachycardia, no P waves Atrial Fibrillation
HR 180/min, narrow complex tachycardia, regular, no P waves AVNRT
HR 150/min, narrow complex tachycardia, regular, atrial rate of 300/min, 2:1 block, saw tooth pattern atrial flutter
Not atrial tachycardia (atrial rate too fast)
HR 87/min, narrow complex, regular, 2:1 block, atrial rate of 150/min,
Not atrial flutter because atrial rate is much lower than that
110/min, narrow complex tachycardia, irregular, no P waves, coarse baseline Atrial fibrillation
110/min, narrow complex tachycardia, irregular, atrial rate of 300/min, variable ventricular response, atrial flutter with variable block
HR 150/min, narrow complex tachycardia, regular, retrograde P wave, short RP, AVNRT
HR 115/min, narrow complex tachycardia, 2:1 block, atrial rate of 230/min, baseline between the P waves in II, III, aVF
210/min, narrow complex tachycardia, irregular, no P waves, A fib
HR 140/min, narrow complex tachycardia, regular, borderline abnormal P, biphasic in II, III, aVF, Long RP atrial tachycardia
