Broad complex tachycardia

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  • 1. K.M.JEYABALAJIDr.P. VIJAYARAGAVANS UNIT

2. HISTORY A 22 yr male patient came with complaints of Acute onset breathlessness Palpitation Profuse sweating Vague chest discomfortFor past 1 hour 3. EXAMINATION Dyspnoeic, tachypnoeic, Pulse- 180/ min REGULAR BP- 90/ 60 mmhg JVP- --- CVS- s1,s2 heard RS NVBS P/A- soft CNS- NFND 4. ADMISSION ECG 5. CHEST LEADS 6. FINDINGS TACHYCARDIA REGULAR RHYTM RATE- 200/min AXIS EXTREME NORTH ( northwest) WIDE QRS COMPLEX RBBB PATTERN IN V1 7. DD FOR WIDE COMPLEXTACHYCARDIA Ventricular tachycardia (VT) Supraventricular tachycardia(SVT) with Aberrancy SVT with drug or electrolyteinduced QRS widening 8. APPROACH WIDE COMPLEX TACHYCARDIAREGULAR/IRREGULARAV DISSOCIATIONCLASSICAL BUNDLE BRANCH MORPHOLOGY BRUGADA CRITERIA AVR CRITERIA 9. BRUGADA CRITERIA YESAbsence of RS complex in V1 V6 VTRS complex duration > 100 ms VTAV dissociationVTMorphology criteriaVT 10. BRUGADA CRITERIA 11. MORPHOLOGY CRITERIAFor RBBB-type complexesIs there an rSR morphology in V1?Is there an RS complex in V6 (smallseptal q OK)?Is the R/S ratio in V6 > 1?For LBBB-type complexesIs 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 aQ? 12. AVR CRITERIA Presence of an initial R wave Width of an initial r or q wave >40 ms, Notching on the initial downstroke of a predominantlynegative QRS complex Ventricular activationvelocity ratio (vi/vt), the verticalexcursion (in millivolts) recorded during the initial (vi)and terminal (vt) 40 ms of the QRS complex. Whenany of criteria 1 to 3 was present, VT was diagnosed;when absent, the next criterion was analyzed. In step4, vi/vt >1 suggested SVT, and vi/vt 1 suggested VT. 13. VENTRICULAR TACHYCARDIA Absence of typical RBBB or LBBB morphology Extreme axis deviation (northwest axis) Very broad complexes (>160ms) AV dissociation (P and QRS complexes at differentrates) Capture beats occur when the sinoatrial nodetransiently captures the ventricles, in the midst of AVdissociation, to produce a QRS complex of normalduration. Fusion beats occur when a sinus and ventricularbeat coincides to produce a hybrid complex. 14. Positive or negative concordance throughout the chestleads, i.e. leads V1-6 show entirely positive (R) orentirely negative (QS) complexes, with no RScomplexes seen. Brugadas sign The distance from the onset of theQRS complex to the nadir of the S-wave is > 100ms Josephsons sign Notching near the nadir of the S-wave 15. VTCAPTURE BEAT FUSION BEAT BRUGADA SIGN , JOSEPHSON SIGN 16. NEGATIVE CONCORDANCE POSITIVE CONCORDANCE 17. 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) 18. VT AGAINST VT Northwest axis Hemodynamically stable Pseudo RBBB No previous MI, CMmorphology Vi/Vt > 1 BRUGADA CRITERIA No fusion, capture beat. AVR CRITERIA no concordance Very broad QRS complex> 160 ms 19. FASCICULAR VT SUPERIOR AXIS PSEUDO RBBB MORPHOLOGY HEMODYNAMICALLY STABLE 20. TAKE HOME MESSAGE No criteria is 100% sensitive nor specific Never go blindly by ECG Give equal imortance to history, clinicalpresentation, Vitals If you are 100% sure that it is SVT, thenproceed. Having even 1% doubt, then treat it as VT 21. THANK YOU

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