This document discusses two cases of wide complex tachycardia. For the first case, the ECG shows features favoring ventricular tachycardia including RS complex in V4, RWPT over 50ms, and history of myocardial infarction. The diagnosis is concluded to be ventricular tachycardia with left bundle branch block morphology. For the second case, the ECG shows features favoring supraventricular tachycardia with aberrant conduction including RS duration under 100ms and RWPT under 50ms. The document also briefly discusses the discovery of defibrillation by Prevost and Batelli in 1899.

1. WIDE COMPLEX TACHYCARDIA

2. CASE 1
50 yr old male, labourer,
smoker with H/O OF MI
5yr back admitted in
ICCU with c/o of
palpitation, feeling of
uneasiness for duration
of 4-6 hrs.
• no h/o chest pain,
dyspnoea, syncope
• o/e-
• conscious,oriented
• no pallor, cyanosis,
clubbing, edema JVP
raised.
• BP-80/60 mm hg

3. DIFFERENTIAL
DIAGNOSIS
Ventricular
tachycardia
Supra ventricular
tachycardia with
abberant conduction
due to right or left
BBB

4. DISCUSSION –
WIDE COMPLEX
TACHYCARDIAS
Definition
ECG features
Diagnostic criteria
• Brugada criteria
• Lead aVR algorithm
Ultrasimple Brugada criterion:
RW to peak Time (RWPT)

5. DEFINITION
Wide QRS complex
tachycardia is a
rhythm with a
rate of more than
100 b/m and QRS
duration of more
than 120 ms
VT (80%)
SVT (20%)

6. • VT- Non-sustained VT: three or more ventricular
beats with a
• maximal duration of 30 seconds.
• Sustained VT: a VT of more than 30 seconds
duration (or less if treated by electrocardioversion
within 30 seconds).
• Monomorphic VT: all ventricular
beats have the same configuration.
• Polymorphic VT: the ventricular beats
have a changing configuration. The RR
interval is 180-600 ms
• Biphasic VT: a ventricular tachycardia with a QRS
complex that alternates from beat to beat.
• SVT- a tachycardia dependent on participation of
structure at or above bundle of His
• LBBB morphology- QRS > 12 msec. with prominent
negative
• deflection in V1
• RBBB morphology- QRS > 12 msec. with prominent
positive deflection in V1.

7. PHYSICAL EXAMINATION
Termination of WCT with maneuvers ~ carotid,
Valsalva, adenosine favors SVT.
hypotension
Signs of AV dissociation favours VT
cannon waves varying intensity of S1 variation of systolic BP

8. BRUGADA CRITERIA

9. STEP 1- RS COMPLEX IN PRECORDIAL LEADS

10. STEP 2- R TO NADIR OF S (BRUGADA SIGN)

11. STEP 3- A-V DISSOCIATION

12. STEP 4- QRS MORPHOLOGY

13. OTHER ECG FINDINGS FAVOUR VT
• North - west QRS axis deviation i.e superior and rightward
• minus 90 degree to 180 degree
• Negative or positive concordance of QRS complex in all
precordial leads
• AV dissociaton : Fusion beats, capture beats
• In LBBB, QRS duration >160 ms
• In RBBB,QRS duration > 140 ms
• Previous ECG show MI

14. RABBIT EAR IN RBBB PATTERN

15. CONCORDANCE & NORTH WEST AXIS

16. POSITIVE CONCORDANCE

17. FUSION & CAPTURE BEATS
A fusion beat is descriptive term for the merging of an ectopic beat and a
capture beat.
• When an ectopic rhythm is present, as in ventricular tachycardia, the ectopic foci may conduct in
a retrograde direction. If the ventricles are not refractory, this leads to a conducted P wave that
causes a normal QRS to follow. This is a capture beat. However, when the ectopic focus fires at
the same time that the P wave reaches the ventricles, the QRS is a "combination" of the capture
and ectopic morphology.
So, ECG strip shows series of ectopic beats (a run of Vtach; the ectopic
rhythm) followed by capture beats (normal configuration; the sinus rhythm)
and then a gradual merging of the capture beats into the ectopic beats.

18. AVR ALGORITHM

19. If the distance traveled on the Y axis in the initial
40ms of the QRS complex is smaller than that
traveled in the terminal 40ms of the QRS complex, a
VT is much more likely

20. ULTRASIMPLE BRUGADA CRITERION: RW TO PEAK
TIME (RWPT)
In 2010 Joseph Brugada et al.
published a new criterion to
differentiate VT from SVT in
wide complex tachycardias:
the R wave peak time in Lead
II [4].
They suggest measuring the
duration of onset of the QRS
to the first change in polarity
(either nadir Q or peak R) in
lead II. If the RWPT is ≥ 50ms
the likelihood of a VT very
high (positive likelihood ratio
34.8).

22. ECG DISCUSSION
• Rate : 180 ventricular rate
• Rhtdym : regular
• Axis : normal
• P wave not clearly discernable
• QRS COMPLEX: Slurred wide complex of
duration
• 200msec
• QS PATTERN in V1 to V4
• BRUGADA’s criteria
• Step 1: RS complex inV4 lead
• Step 2 : RS duration is 120msec
• All these favours VT

23. • AVR ALGORITM
• Step 1: intial r wave : absent
• Step 2: r wave is 50 msec
• This favours VT
• Ultrasimple Brugada criterion: RW
to peak Time (RWPT)
• Here RWPT IS 60msec
• This favors VT

24. OUR ECG
 Axis is normal
 Not typical vt LBB
morphology
 Qrs duration .14 s with
lbbb
 Non concordance
 Presence of RS complex
Favours VT
 h/o MI
 V4 RS complex
duration RS >100 ms
 A-v dissociation
 Avr s/o vt
 RWPT > 50ms
Against VT

25. CONCLUSION-
DIAGNOSIS
• VENTRICULAR
TACHYCARDIA
WITH LBBB
•MORPHOLOGY
• CAD- OLD
ANT.SEPTAL MI

26. CASE 2
• A 26yrs old man
presented to emergency
with complaints of
feeling of uneasiness ,
heaviness in chest,
dyspnoea with no
significant past history
of any medical illness
• O/E
• BP 80/60
• No
P/CY/CL/ICT/LAP/EDEM
A

29. DISCUSSION
Rate : 210 ventricular rate Rhythm : not sinus
P wave can't be discernable
QRS COMPLEX : Wide ; duration is nearly 160 msec
Concordance: NO
Fusion beats and AV dissociation : NO
Applying Brugada algorithm
Step 1: rS complex present
Step 2: rS complex duration: here 80msec Step 3: av dissociation here absent
Step 4 : morphological criteria
RBBB pattern is present In V1 : rSR pattern
In V6 : height of S > R so R/S > 1
All these finding favours that it is SVT with abberancy

30. AVR
algorithm
Intial R wave in AVR : NO Wave r
= 40 msec
No notching in decending limb and no
negative predominace of QRS Vi < Vt
All these favours SVT with abberancy
Ultrasimple Brugada criterion: RW to
peak Time (RWPT)
HERE RWPT is 40msec in Lead II
So, it is favours SVT with abberancy

31. PREVOST BATELLI
DISCOVERY OF DEFIBRILLATOR
Defibrillation was invented in 1899 by Prevost and Batelli,
Two physiologists from University of Geneva, Switzerland. They discovered
that small electric shocks could induce ventricular fibrillation in dogs, and that
larger charges would reverse the condition.