Wide FLB’s and QRS Tachycardias Reading Assignment (p30-41 and 42-44) Welcome to the “5-Step Method” ECG #: Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= V= PR= QRS= QT= Axis= 1. Compute the 5 basic measurements: HR, PR interval, QRS duration, QT interval, Axis 2. What’s the basic rhythm and other rhythm statements (e.g., PACs and PVC’s) 3. Any conduction abnormalities (SA blocks, AV blocks (Types I or II), and IV blocks 4. Waveform abnormalities beginning with P waves, QRS complexes, ST-T, and U waves 5. Final interpretations: Normal ECG or Borderline or Abnormal ECG (list final conclusions) 44 Year old man in the ER with palpitations and lightheadedness 7-1 rsR’ Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= V=210 Wide QRS tachycardia • IVCD • rsR‘ in V1 Abnormal ECG: • Late S (rightward forces) in 1. High probability SVT with RBBB PR= I, aVL, V6 Clues: classic triphasic (rsR‘) RBBB QRS=1120 morphology in V1 is very unlikely to be VT. The most likely SVT mechanism in this QT=240 ECG is AVNRT with RBBB. 7-1 Axis= indeterminate 65 Year old man in the ICU with hypotension 7-2 qR in V1 rS in V6 Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= V=140 Wide QRS tachycardia • IVCD • Northwest quadrant axis Abnormal ECG: (lead I and II both negative) • Left ventricular tachycardia PR= • qR pattern in V1 • rS pattern in V6 ECG Clues for VT in this case: 1) NW QRS=150 quadrant axis; 2) qR in V1; rS in V6. QT=340 Clinical clues: hypotension 7-2 Axis= -120 (NW Quadrant) I II III 7-3 75 Year old man in the ICU with recent acute coronary syndrome Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= V= 135 Wide QRS tachycardia • IVCD • fat R in V1 (red arrows) Abnormal ECG: • Notch on downstroke of S 1. Right ventricular tachycardia PR= in V1 (blue arrows) QRS=160 • >60 ms delay from QRS Clues: classic VT morphology in lead V1 QT=360 onset to S wave nadir in V1 (RV origin) Axis= +30 I >60 ms II III 7-3 75 Year old man in the ICU with recent acute coronary syndrome M, Age 66 7-4 M, Age 66 Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A=100 V=110 • Sinus tachycardia • AV dissociation • Notch on downstroke of S Abnormal ECG: • PR= (red arrows) IVCD due to in V1 (blue arrow) 1. Right ventricular tachycardia • Wide QRS sequential • >60 ms delay from QRS with incomplete AV QRS=170 tachycardia (VT) ventricular onset to S nadir in V1 dissociation from the QT=320 • One PVC (*) from LV activation (VT) (black arrows) competing sinus tachycardia • Axis= +90 One fusion beat (F) • One sinus capture (C) VT Clues: V1 QRS morphology; AV dissociation with fusions and captures * C F 7-4 M, Age 64 I II III 7-5 M, Age 64 I II III Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= V= 200 Ventricular tachycardia IVCD due to sequential • Concordant QRS Abnormal ECG: ventricular activation complexes V1-6 (all QRS‘s • Ventricular tachycardia PR= during VT in same direction) favors VT diagnosis Another VT clue: initial part of QRS moves QRS=150 more slowly than later parts suggesting origin in ventricular muscle rather than QT=320 Purkinje network (see V2, for example) Axis= +105 7-5 I II III 56 year old man with long history of intermittent palpitations 7-6a I II III Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= V= ~200 Atrial fibrillation with Variable IVCD (QRS‘s • Irregular wide QRS Abnormal ECG: rapid HR with varing duration) tachycardia • Rhythm (A-fib) PR= none • Concordant QRS V1-6 • Accessory pathway (WPW) QRS= ~140 (but variable) Clue: some QRS‘s occur at >300 bpm (see arrows). The AV node can‘t conduct that QT= ~280 fast; i.e., use of accessory pathway. 7-6a Axis= -40 I II III 56 year old man with long history of intermittent palpitations (after a treatment) 7-6b I II III Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A=45 V=45 Marked sinus bradycardia • short PR • delta waves are negative in Abnormal ECG: • IVCD II, III, aVF looking like • WPW type preexcitation PR=110 (short) pathologic Q-waves • Heart rate (sinus bradycardia) (arrows) QRS=11o When this person goes into atrial fibrillation (see previous ECG) there is QT=440 very rapid conduction with variable wide QRS morphology) 7-6b Axis= -10 47 year old woman with recent onset of palpitations 7-7 2:1 LBBB Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= V= 160 Supraventricular 2:1 LBBB Alternating notched Abnormal ECG: tachycardia monophasic R in I, aVL, V6 • Rhythm/Rate: SVT (probably AVNRT) PR= (LBBB) • Conduction (2:1 LBBB) QRS= 100 & 130 Note: This is an unusual SVT due to the alternating 2:1 LBBB. At a slower rate all QT= ~260 the QRS‘s would likely be narrow. 7-7 Axis= -30 Check out the V1 rhythm strip 7-8 * * Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= ~75 V= ~75 Sinus rhythm (1st 2 beats) • RBBB (1st 2 beats) • rSR‘ (1st 2 beats) Abnormal ECG: followed by accelerated • Fusion beats (*); when the • RBBB PR= ~200 (1st 2 beats) ventricular rhythm (from ventricular rhythm begins • Isochronic ventricular rhythm (note the LV; also called an there is also partial the subtle AV dissociation (shortening QRS= 140 ‘isochronic’ ventricular conduction from the sinus of PR intervals) during the ventricular rhythm due to a similar rhythm into the ventricles. rhythm) QT= 400 HR as the sinus rate) 7-8 Axis= +75 67 y.o. man with syncope; brother died suddenly 10 yrs. ago 7-9a HR: 190 bpm QRS: 120 ms QT: ~240 ms Axis: +100 Rhythm: Ventricular tachycardia (RV outflow track origin; note the inferior frontal plane axis of +100 degrees and LBBB like QRS) Waveform: wide QRS with slurred V1 downstroke Abnormal ECG: VT 67 y.o. man with syncope; brother died suddenly 10 yrs. ago 7-9a 67 y.o. man with syncope; post cardioversion 7-9b Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= 65 V= 65 Sinus rhythm Normal SA, AV, IV • Very tiny Epsilon waves V1-3 Abnormal ECG: conduction (arrows) • Arrhythmogenic right ventricular PR=200 • T wave inversion V1-4 dysplasia (ARVD) • T wave abnormalities (V1-4) associated with ARVD QRS=80 Epsilon waves are subtle indicators of QT=400 altered conduction in the RV outflow track associated with high risk of RVOT Axis= 0 tachycardias (see previous ECG 7-9a) and sudden cardiac death. 7-9b 25 year old man ‘found down’ in bathroom: rhabdomyolysis and acute renal failure; admitted to shock/trauma unit. 7-10a J F J F J F J F J F J F J F Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= V= ~90 • Accelerated junctional rhythm (J) Normal IV • T inversion V1-3 Abnormal ECG: 1. Parasystolic ventricular rhythm PR= • Competing parasystolic ventricular 2. Accelerated junctional rhythm rhythm with fusion beats (F); Note 3. Nonspecific T abnormalities QRS= 80 (junctional the constant RR interval between beats) the parasystolic beats (F) as they Note: the fusion beats result from the QT=360 merge with the junctional beats (J) merger of an RV ectopic focus with the 7-10a Axis= +60 Amazing! accelerated junctional beats. 25 year old man ‘found down’ in bathroom: rhabdomyolysis and acute renal failure; admitted to shock/trauma unit. 7-10b Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= V= ~85 • Accelerated junctional Normal IV • Normal QRS Abnormal ECG: rhythm • Minor T inversion (V2) 1) Rhythm PR= • PVC’s (RV origin) in a 2) Prolonged QT (for heart rate) pattern of bigeminy QRS=70 QT= ~420 7-10b Axis= +60 9-May-2014: LS: 70 y man; status post aortic valve replacement and quad CABG A funny thing happened on the way through the left bundle ! 7-11 * ** *** * ** *** * ** *** * Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= 65 V= 65 Sinus rhythm • 1st degree AVB ST-T changes secondary to the Abnormal ECG: • 2nd degree LBBB (note the 3 LBBB 1. 1st degree AV block PR=240 different LBBB morphologies: 2. Incomplete LBBB incomplete *, more QRS=110 - 160 incomplete **, and complete (Is there such a thing as LBBB ***) Wenckebach, or is it just an increasingly QT= 440 - 560 tired left bundle ?) 7-11 Axis= Normal 83 year old woman; dyspnea and fatigue 7-12 * Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= 100 V=100 & 170 • Sinus tachycardia and • Normal SA, AV Secondary ST-T changes of Abnormal ECG: PR=160 • Probable A-fibrillation • LBBB LBBB 1. Heart rate (tachycardia) beginning with arrow (note 2. Rhythms (Sinus tachy, A-Fib with RVR, QRS=120 slight irregularity of RR) and a PVC) 7-12 QT=360 • One PVC (*) 3. Conduction (LBBB) Axis= +15.