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MALIGNANT ARRHYTHMIAS: ECG IDENTIFICATION

MALIGNANT ARRHYTHMIAS: ECG IDENTIFICATION. DR.SIVAKUMAR ARDHANARI MD. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Normal sinus rhythm. Impulse formation beginning in the sinus node At frequencies between 60 to 100 per minute P is always upright in I, II and aVF and inverted in aVR

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MALIGNANT ARRHYTHMIAS: ECG IDENTIFICATION

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  1. MALIGNANT ARRHYTHMIAS:ECG IDENTIFICATION DR.SIVAKUMAR ARDHANARI MD www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  2. Normal sinus rhythm • Impulse formation beginning in the sinus node • At frequencies between 60 to 100 per minute • P is always upright in I, II and aVF and inverted in aVR • Though rhythm is regular, minor variation in PP interval exists & longest and shortest PP differ< 0.16 except in sinus arrhythmia

  3. Normal sinus rhythm • Every P is followed by a QRS complex • Every QRS is preceded by a P wave • P and its following QRS is separated by fairly regular PR interval • TO BE VERY PRECISE P AND QRS ARE IN SIMPLE HARMONY

  4. NORMAL ECG

  5. When the rhythm deviates from the above said normalcy it is called ARRHYTHMIA • Broadly it is classified as brady and tachy arrhythmia • Arrhythmogenesis may be due various causes

  6. Some arrhythmias are considered MALIGNANT • Because if not properly and immediately treated, it can be LETHAL to the sufferer • This is important in understanding the concept of SUDDEN CARDIAC DEATH

  7. SUDDEN CARDIAC DEATH

  8. Anatomy of the conduction system

  9. Anatomy of the conduction system • Sinus node- • RCA (55-60%) • left circumflex (40-45%)artery • AV node- • RCA (85-90%) • left circumflex (10-15%) artery

  10. ACUTE RVMI+IWMI

  11. Anatomy of conduction system • The conduction system is densely innervated by • Cholinergic fibers- parasympathetic • Adrenergic fibers- sympathetic • This is important in understanding • variability of cardiac function with autonomic influence • effect of parasympathetic stimulation in terminating arrhythmias

  12. BRADYARRHYTHMIAS • Sinus nodal • Sinus bradycardia • Sinus arrhythmia • Sinus pause/arrest • Sinoatrial exit block • Sick sinus syndrome • AV nodal blocks • First degree • Second degree(MOBITZ type 1 and 2) • Complete heart block

  13. SINUS ARREST

  14. SICK SINUS SYNDROME

  15. ATRIO VENTRICULAR BLOCK • I degree -conduction time prolonged: all impulses are conducted • II degree -2 forms • Mobitz type I (WENCKEBACH)- progressive lengthening of conduction time until an impulse is failed to be conducted • Mobitz type II- occasional or repetitive sudden block in conduction without prior measurable lengthening of conduction time • Complete or III degree -no impulses are conducted

  16. FIRST DEGREE AV BLOCK

  17. FIRST DEGREE HB

  18. IWMI+FIRST AV BLOCK

  19. 2:1 AV BLOCK

  20. COMPLETE AV BLOCK • Occurs when no atrial activity is conducted to the ventricles • So atria and ventricles are controlled by independent pacemakers • One type of complete AV dissociation • Ventricular focus is usually just below the site of block • If focus near HIS bundle the rhythm is more stable

  21. CHB can occur at various levels • AV Node-usually congenital-40-60 bpm • Bundle of HIS • Purkinje sys-usually acquired-

  22. COMP HEART BLOCK

  23. COMP HB

  24. CHB

  25. CHB

  26. IWMI+CHB

  27. APPROACH TO TACHYCARDIA

  28. ATRIAL FLUTTER • F waves: rapid regular undulations SAW TOOTH APPEARANCE • Atrial rate:250-350 bpm • Rate & regularity of ventricles: variable and depend on AV conduction sequence • QRS may be normal or abnormal as a result of preexisting intraventricular conduction defect or aberrancy

  29. ATRIAL FLUTTER

  30. ATRIAL FLUTTER

  31. ATRIAL FLUTTER

  32. SVT VS VT

  33. Differentiating a VT from SVT can be difficult at times • Golden rule in ER ANY WIDE QRS TACHYCARDIA IS VENTRICULAR TACHYCARDIA UNTIL PROVED OTHERWISE ESP`LY WHEN THE PATIENT HAS A STRUCTURAL HEART DISEASE

  34. Diagnosis of VT • Arises distal to the bifurcation of the HIS bundle • Diagnosis is by the occurrence of a series of 3 or more consecutive, abnormally shaped PVCs whose duration exceeds 120 ms, with ST-T vector pointing opposite the major QRS deflection

  35. VENTRICULAR ECTOPICS

  36. RR can be exceedingly regular or can vary • Atrial activity can be independent of ventricular activity or can be depolarized retrograde (VA association)

  37. Fusion beats and capture beats provide the maximum support for the diagnosis of VT • FUSION BEATS-activation of ventricles from 2 foci • CAPTURE BEATS- capture of the ventricle by supraventricular rhythmwith normal confguration of the captured QRS at intrvl shorter than tachycardia in question- indicates origin of impulse is supraventricular

  38. FUSION AND CAPTURE BEATS

  39. QRS contours can be • Unchanging (MONOMORPHIC) • Vary randomly (POLY OR PLEOMORPHIC) • Vary repetitively (TORSADES DE PONTES) • Vary in alternative cplxs (BIDIRECTIONAL)

  40. MONOMORPHIC VT

  41. POLYMORPHIC VT

  42. TORSADES DE POINTES

  43. TYPES OF VT VT can be • SUSTAINED- lasting longer than 30 seconds or requiring termination due to hemodynamic collapse • NON SUSTAINED- stops spontaneously within 30 seconds

  44. NON-SUSTAINED VT

  45. SUSTAINED VT

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