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| [[File:Siren.gif|30px|link=Wide complex tachycardia resident survival guide]]|| <br> || <br>
| [[Wide complex tachycardia resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{{Wide complex tachycardia}}
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{{CMG}}


==Overview==
==Overview==
There are several EKG criteria that may help differentiate [[ventricular tachycardia]] ([[VT]]) from [[supraventricular tachycardia]] ([[SVT]]) with aberrancy in the patient with a wide complex tachycardia. The diagnosis of [[VT]] is more likely if the [[electrical axis]] is -90 to -180 degrees (a “northwest” or “superior” axis), if the [[QRS]] is > 140 msec, if there is [[AV dissociation]],  if there are positive or negative [[QRS]] complexes in all the precordial leads, and if the morphology of the [[QRS]] complexes resembles that of a previous [[premature ventricular contraction]] ([[PVC]]).


Shown below are examples of wide complex tachycardias and their diagnosis.
==EKG Examples==
----
Shown below is an [[EKG]] demonstrating [[VT]] with [[right bundle branch block]].
'''Case 1:'''
VT with right bundle branch block morphology:
[[File:VT with RBBB morphology.jpg|center|800px]]
[[File:VT with RBBB morphology.jpg|center|800px]]
 
Copyleft images obtained courtesy of ECGpedia.<ref name="ecg">ecgpedia.org</ref>
----
----
'''Case 2:'''
Shown below is an EKG demonstrating [[sinus tachycardia]] and [[WPW]] which mimics [[VT]].
Shown below is a patient with sinus tachycardia and [[WPW]] which mimics VT:


[[File:WPW with sinus tachycardia mimicking VT.jpg|center|800px]]
[[File:WPW with sinus tachycardia mimicking VT.jpg|center|800px]]
====Interpretation of the Previous ECG====


ECG pedia suggests the 7 + 2 method to interpret the above EKG:
====Rhythm====
 
===Rhythm===


* This is a regular rhythm and every QRS complex is preceded by a p wave. The p wave is positive in II,III, and AVF and thus originates from the sinus node. Conclusion: sinus rhythm.
* This is a regular rhythm and every [[QRS complex]] is preceded by a [[P wave]]. The [[P wave]] is positive in II,III, and AVF and thus originates from the [[sinus node]]; hence, this is a [[sinus rhythm]].


===Rate===
====Rate====


* Use the 'count the squares' method (a bit less than 3 large squares ~> 300-150-100), thus about 110 bpm and thus sinustachycardia.
* Use the 'count the squares' method (a bit less than 3 large squares ~> 300-150-100), thus about 110 bpm and thus sinustachycardia.


===Conduction (PQ,QRS,QT)===
====Conduction (PQ,QRS,QT)====
 
* PQ-interval=0.10sec (2.5 small squares), QRS duration=0.10sec, QT interval=320ms


===Axis===
* PQ-interval=0.10sec (2.5 small squares), [[QRS]] duration=0.10sec, [[QT]] interval=320ms


* Positive in I, II, negative in III and AVF. Thus a horizontal (normal) heart axis.
====Axis====
* The EKG depicts a horizontal normal [[heart axis]] as there are positive deflections in leads I and II and negative deflections in leads III and AVF.


===P wave morphology===
====P wave morphology====


* The p wave is rather large in II, but does not fulfill the criteria for right atrial dilatation.
* The [[P wave]] is rather large in II, but does not fulfill the criteria for right atrial dilatation.


===QRS morphology===
====QRS morphology====


* The QRS shows a slurred upstroke or delta wave.
* The [[QRS]] shows a slurred upstroke or [[delta wave]].


===ST morphology===
====ST morphology====


* Negative T wave in I and AVF. Flat ST in V3-V5.
* There is a negative [[T wave]] in I and AVF in addition to a flat [[ST segment]] in V3-V5.<ref name="ecg">ecgpedia.org</ref>


Compare with the old ECG (not available, so skip this step)
----
----
'''Case 3'''
Shown below is an [[EKG]] demonstrating wide complex tachycardia at a rate of 160/min with a [[RBBB]], [[AV dissociation]], and extreme [[right axis deviation]] as both leads I and aVF are directed downwards.  These findings favor [[VT]].
Shown below is a wide complex tachycardia:
[[File:Wide complex tachycardia 1.jpg|center|800px]]
[[File:Wide complex tachycardia 1.jpg|center|800px]]


A broad complex tachycardia at a rate of 160/min with a RBBB configuration is present.  The following findings favor VT as a diagnosis:
Shown below is an [[EKG]] of the same patient after 7.5 mg [[verapamil]] was administered, which slowed the [[VT]] and caused the [[AV dissociation]] to become more apparent.
*Extreme right axis deviation. Both I and avF are downward.
*AV dissociaiton
 
7.5 mg verapamil was administered, which slowed the VT, and [[AV dissociation]] is now more apparent:
 
[[File:Wide complex rhythm with AV dissociation.jpg|center|800px]]
[[File:Wide complex rhythm with AV dissociation.jpg|center|800px]]


Ultimately converted the patient to sinus rhythm:
Shown below is an [[EKG]] of the same patient who ultimately converted to [[sinus rhythm]].
 
[[File:Wide complex rhythm converted to NSR.jpg|center|800px]]
[[File:Wide complex rhythm converted to NSR.jpg|center|800px]]
Copyleft images obtained courtesy of ECGpedia.<ref name="ecg">ecgpedia.org</ref>
----
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[[Category:Electrophysiology]]
[[Category:Electrophysiology]]
[[Category:Cardiology board review]]
[[Category:Cardiology board review]]
{{WH}}
{{WS}}

Latest revision as of 19:28, 5 August 2013



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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

There are several EKG criteria that may help differentiate ventricular tachycardia (VT) from supraventricular tachycardia (SVT) with aberrancy in the patient with a wide complex tachycardia. The diagnosis of VT is more likely if the electrical axis is -90 to -180 degrees (a “northwest” or “superior” axis), if the QRS is > 140 msec, if there is AV dissociation, if there are positive or negative QRS complexes in all the precordial leads, and if the morphology of the QRS complexes resembles that of a previous premature ventricular contraction (PVC).

EKG Examples

Shown below is an EKG demonstrating VT with right bundle branch block.

Copyleft images obtained courtesy of ECGpedia.[1]


Shown below is an EKG demonstrating sinus tachycardia and WPW which mimics VT.

Interpretation of the Previous ECG

Rhythm

Rate

  • Use the 'count the squares' method (a bit less than 3 large squares ~> 300-150-100), thus about 110 bpm and thus sinustachycardia.

Conduction (PQ,QRS,QT)

  • PQ-interval=0.10sec (2.5 small squares), QRS duration=0.10sec, QT interval=320ms

Axis

  • The EKG depicts a horizontal normal heart axis as there are positive deflections in leads I and II and negative deflections in leads III and AVF.

P wave morphology

  • The P wave is rather large in II, but does not fulfill the criteria for right atrial dilatation.

QRS morphology

ST morphology


Shown below is an EKG demonstrating wide complex tachycardia at a rate of 160/min with a RBBB, AV dissociation, and extreme right axis deviation as both leads I and aVF are directed downwards. These findings favor VT.

Shown below is an EKG of the same patient after 7.5 mg verapamil was administered, which slowed the VT and caused the AV dissociation to become more apparent.

Shown below is an EKG of the same patient who ultimately converted to sinus rhythm.

Copyleft images obtained courtesy of ECGpedia.[1]


References

  1. 1.0 1.1 1.2 ecgpedia.org

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