ECG: Wide Complex Tachycardia

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ECG: Wide Complex Tachycardia

  1. 1. K.M.JEYABALAJI Dr.P. VIJAYARAGAVAN’S UNIT
  2. 2. HISTORY <ul><li>A 22 yr male patient came with complaints of </li></ul><ul><ul><li>Acute onset breathlessness </li></ul></ul><ul><ul><li>Palpitation </li></ul></ul><ul><ul><li>Profuse sweating </li></ul></ul><ul><ul><li>Vague chest discomfort </li></ul></ul><ul><ul><ul><li>For past 1 hour </li></ul></ul></ul>
  3. 3. EXAMINATION <ul><ul><li>Dyspnoeic, tachypnoeic, </li></ul></ul><ul><ul><li>Pulse- 180/ min REGULAR </li></ul></ul><ul><ul><li>BP- 90/ 60 mmhg </li></ul></ul><ul><ul><li>JVP- --- </li></ul></ul><ul><ul><li>CVS- s1,s2 heard </li></ul></ul><ul><ul><li>RS – NVBS </li></ul></ul><ul><ul><li>P/A- soft </li></ul></ul><ul><ul><li>CNS- NFND </li></ul></ul>
  4. 4. ADMISSION ECG
  5. 5. CHEST LEADS
  6. 6. FINDINGS <ul><li>TACHYCARDIA </li></ul><ul><li>REGULAR RHYTM </li></ul><ul><li>RATE- 200/min </li></ul><ul><li>AXIS – EXTREME NORTH ( northwest) </li></ul><ul><li>WIDE QRS COMPLEX </li></ul><ul><li>RBBB PATTERN IN V1 </li></ul>
  7. 7. DD FOR WIDE COMPLEX TACHYCARDIA <ul><li>Ventricular tachycardia (VT) </li></ul><ul><li>Supraventricular tachycardia (SVT) with Aberrancy </li></ul><ul><li>SVT with drug or electrolyte induced QRS widening </li></ul>
  8. 8. APPROACH WIDE COMPLEX TACHYCARDIA REGULAR/IRREGULAR AV DISSOCIATION CLASSICAL BUNDLE BRANCH MORPHOLOGY BRUGADA CRITERIA AVR CRITERIA
  9. 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. 10. BRUGADA CRITERIA
  11. 11. MORPHOLOGY CRITERIA <ul><li>For RBBB-type complexes </li></ul><ul><li>Is there an rSR’ morphology in V1? </li></ul><ul><li>Is there an RS complex in V6 (small </li></ul><ul><li>septal q OK)? </li></ul><ul><li>Is the R/S ratio in V6 > 1? </li></ul><ul><li>For LBBB-type complexes </li></ul><ul><li>Is there an rS or QS complex in V1 and V2? </li></ul><ul><li>Is the onset of the QRS to the nadir of the S in V1 < 70 ms? </li></ul><ul><li>Is there an R wave in lead V6 without a </li></ul><ul><li>Q? </li></ul>
  12. 12. AVR CRITERIA <ul><li>Presence of an initial R wave </li></ul><ul><li>Width of an initial r or q wave >40 ms, </li></ul><ul><li>Notching on the initial downstroke of a predominantly negative QRS complex </li></ul><ul><li>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. </li></ul>
  13. 14. VENTRICULAR TACHYCARDIA <ul><li>Absence of typical RBBB or LBBB morphology </li></ul><ul><li>Extreme axis deviation (“northwest axis”) </li></ul><ul><li>Very broad complexes (>160ms) </li></ul><ul><li>AV dissociation (P and QRS complexes at different rates) </li></ul><ul><li>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. </li></ul><ul><li>Fusion beats — occur when a sinus and ventricular beat coincides to produce a hybrid complex. </li></ul>
  14. 15. <ul><li>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. </li></ul><ul><li>Brugada’s sign –  The distance from the onset of the QRS complex to the nadir of the S-wave is > 100ms </li></ul><ul><li>Josephson’s sign  – Notching near the nadir of the S-wave </li></ul>
  15. 16. VT CAPTURE BEAT FUSION BEAT BRUGADA SIGN , JOSEPHSON SIGN
  16. 17. <ul><li>NEGATIVE CONCORDANCE POSITIVE CONCORDANCE </li></ul>
  17. 18. SVT WITH ABBERANCY <ul><li>• Any SVT can be conducted with aberrancy: </li></ul><ul><li>– Sinus Tachycardia </li></ul><ul><li>– Atrial tachycardia </li></ul><ul><li>– Atrial flutter </li></ul><ul><li>– Atrioventricular nodal reentrant tachycardia (AVNRT) </li></ul><ul><li>– Junctional Tachycardia </li></ul><ul><li>– Orthodromic Atrioventricular Reentrant Tachycardia </li></ul><ul><li> (AVRT) </li></ul>
  18. 19. VT AGAINST VT <ul><li>Northwest axis </li></ul><ul><li>Pseudo RBBB morphology </li></ul><ul><li>BRUGADA CRITERIA </li></ul><ul><li>AVR CRITERIA </li></ul><ul><li>Very broad QRS complex </li></ul><ul><li>> 160 ms </li></ul><ul><li>Hemodynamically stable </li></ul><ul><li>No previous MI, CM </li></ul><ul><li>Vi/Vt > 1 </li></ul><ul><li>No fusion, capture beat. </li></ul><ul><li>no concordance </li></ul>
  19. 20. FASCICULAR VT <ul><li>SUPERIOR AXIS </li></ul><ul><li>PSEUDO RBBB MORPHOLOGY </li></ul><ul><li>HEMODYNAMICALLY STABLE </li></ul>
  20. 21. TAKE HOME MESSAGE <ul><li>No criteria is 100% sensitive nor specific </li></ul><ul><li>Never go blindly by ECG </li></ul><ul><li>Give equal imortance to history, clinical presentation, </li></ul><ul><li>Vitals </li></ul><ul><li>If you are 100% sure that it is SVT, then proceed. </li></ul><ul><li>Having even 1% doubt, then treat it as VT </li></ul>
  21. 22. THANK YOU

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