ecg: wide complex tachycardia
TRANSCRIPT
K.M.JEYABALAJIDr.P. VIJAYARAGAVAN’S UNIT
HISTORYA 22 yr male patient came with
complaints ofAcute onset breathlessnessPalpitationProfuse sweatingVague chest discomfort
For past 1 hour
EXAMINATION
Dyspnoeic, tachypnoeic, Pulse- 180/ min REGULARBP- 90/ 60 mmhgJVP- ---CVS- s1,s2 heardRS – NVBSP/A- softCNS- NFND
ADMISSION ECG
CHEST LEADS
FINDINGSTACHYCARDIAREGULAR RHYTMRATE- 200/minAXIS – EXTREME NORTH ( northwest)WIDE QRS COMPLEX RBBB PATTERN IN V1
DD FOR WIDE COMPLEX TACHYCARDIA
• Ventricular tachycardia (VT)• Supraventricular tachycardia (SVT) with Aberrancy• SVT with drug or electrolyte induced QRS widening
APPROACH WIDE COMPLEX TACHYCARDIA
REGULAR/IRREGULAR
AV DISSOCIATION
CLASSICAL BUNDLE BRANCH MORPHOLOGY
BRUGADA CRITERIA
AVR CRITERIA
BRUGADA CRITERIAYES
Absence of RS complex in V1 – V6
VT
RS complex duration > 100 ms VT
AV dissociation VT
Morphology criteria VT
BRUGADA CRITERIA
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?
AVR CRITERIAPresence 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.
VENTRICULAR TACHYCARDIAAbsence of typical RBBB or LBBB morphologyExtreme 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.
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
VT
CAPTURE 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– Atrioventricular nodal reentrant tachycardia (AVNRT)– Junctional Tachycardia– Orthodromic Atrioventricular Reentrant Tachycardia (AVRT)
VT AGAINST VTNorthwest axisPseudo RBBB
morphologyBRUGADA
CRITERIAAVR CRITERIAVery broad QRS
complex > 160 ms
Hemodynamically stable
No previous MI, CMVi/Vt > 1No fusion, capture
beat. no concordance
FASCICULAR VT
SUPERIOR AXIS PSEUDO RBBB MORPHOLOGYHEMODYNAMICALLY STABLE
TAKE HOME MESSAGE
No criteria is 100% sensitive nor specificNever go blindly by ECGGive equal imortance to history, clinical
presentation, VitalsIf you are 100% sure that it is SVT, then
proceed.Having even 1% doubt, then treat it as
VT
THANK YOU