E.C.G. Course – V Ventricular rhythms Dr. Michael Kassirer ”Dept. Internal Medicine ”D Tel-Aviv Medical center
Objective By the end of lesson 5 the student will:
Know how to differentiate between APCs and VPCs, and ECG criteria for each.
Be familiar with different forms of ectopic activity
Be able to diagnose the following rhythms: Ventricular tachycardia (mono and polymorphic, V. Fibrillation, Accelerated idio-ventricular rhythms, and asystole.
Know how to differentiate wide complex tachycardia – between ventricular rhythms and
Ventricular premature beat
Wide, Bizzare-shaped QRS complex (Uni or Multifocal) Prematurity (Unlike escape beat) No P before QRS Compensatory Pause – complete
Escape beat
Compensatory Pause
APBs Vs VPBs
APBs = PACs Normal, narrow QRS No P / different P PartialCompensatory period
VPBs = PVCs Wide, Bizzare QRS No P / Retrograde P Compensatory period
Reasons for Ventricular complexes
Normal – (↑ in Anxiety, stress, coffee and more…) Metabolic disturbances Myocardial Ischemia Ventricular aneurism, CMP, CHF Drug intoxication
Escape rhythm in Severe bradycardia
Couplets
Bigeminy
Trigeminy
Ventricular Tachycardia Ventricular tachycardia
160-250 Regular
A-V dissociation
sec 12. >
Accelerated IdioVentricular rhythm (AIVR = (“Slow” VT
Normal Ventricular ”escape" rhythm = 30-40bpm*
Ventricular Fibrillation
Asystole
Wide complex Tachycardia +90%
• Ventricular Tachycardia • AF/AVNRT (SVT) • AIVR With aberrant conduction • WPW • Tachycardia + RBBB / LBB
Wide Complex tachycardia Aberrant conduction
Normal axis Known WPW/BBB P:R Wave ratio = 1:1
Ventricular tachycardia
Abnormal Cardiac Axis (NML). All Complexes same direction in V1-6 (Concordance) AV dissociation Very wide QRS (> .16) In V1 (Brugada criteria): RBBB morphology - Rsr’ pattern