Post on 16-Jul-2015
transcript
WIDE COMPLEX
TACHYCARDIA
VT VS SVT
Presented by
Dr Neeraj Nirala
GUIDE
Dr Neera Samar
UNIT HEAD
Dr R.L. Meena
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
ECG AT TIME OF ADMISSION (BEFORE DC)
ECG AT TIME OF ADMISSION
ECG -AFTER DC CARDIOVERSION (200J)
DIFFERENTIAL DIAGNOSIS
Ventricular tachycardia
Supra ventricular tachycardia with abberant
conduction due to right or left BBB
DISCUSSION –WIDE COMPLEX TACHYCARDIAS
Definition
Ecg features
Diagnostic criteria
- Brugada criteria
- Lead aVR algorithm
- Ultrasimple Brugada criterion:
RW to peak Time (RWPT)
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%)
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.
PHYSICAL EXAMINATION
Signs of AV dissociation favours VT
- cannon waves
- varying intensity of S1
- variation of systolic BP
- hypotension
Termination of WCT with maneuvers ~
carotid,vasalva,adenosine favours SVT
BRUGADA CRITERIA
STEP 1- RS COMPLEX IN PRECORDIAL LEADS
STEP 2- R TO NADIR OF S (BRUGADA SIGN)
STEP 3- A-V DISSOCIATION
STEP.4- QRS MORPHOLOGY
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
RABBIT EAR IN RBBB PATTERN
CONCORDANCE & NORTH WEST AXIS
POSITIVE CONCORDANCE
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.
AVR ALGORITHM
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
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).
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
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
OUR ECG
h/o MI
V4 RS complex
duration RS >100 ms
A-v dissociation
Avr s/o vt
RWPT > 50ms
Axis is normal
Not typical vt LBB
morphology
Qrs duration .14 s with
lbbb
Non concordance
Presence of RS complex
Favours VT •Against VT
CONCLUSION-DIAGNOSIS
VENTRICULAR TACHYCARDIA WITH LBBB
MORPHOLOGY
CAD- OLD ANT.SEPTAL MI
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/EDEMA
CASE 2
DISCUSSION
Rate : 210 ventricular rate
Rhythm : not sinus
P wave cant be discernable
QRS COMPLEX : Wide ; duration is nearly 160 msec
Concordance: NO
Fusion beats and AV dissociation : NO
Applying Brugada algorithmStep 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
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
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.
THANK YOU