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APPROACH TO WIDE QRS COMPLEX TACHYCARDIA Dr HA TUAN KHANH Dr DAVID TRAN.

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Presentation on theme: "APPROACH TO WIDE QRS COMPLEX TACHYCARDIA Dr HA TUAN KHANH Dr DAVID TRAN."— Presentation transcript:

1 APPROACH TO WIDE QRS COMPLEX TACHYCARDIA Dr HA TUAN KHANH Dr DAVID TRAN

2 Content 1.Definition 2.Causes of WCT 3.Diagnosis criteria Clinical history Physical examination ECG criteria: Brugada criteria, other criteria, findings favoring SVT, VT vs AVRT criteria 4.Management Unstable hemodynamic Stable hemodynamic

3 Definition Wide QRS complex tachycardia is a rhythm with a rate of more than 100 b/m and QRS duration of more than 120 ms VT (80%) SVT (20%) Stewart RB. Ann Intern Med 1986

4 Supraventricular tachycardia - with prexsisting BBB - with BBB due to heart rate (aberrant conduction) - antidromic tachycardia in WPW syndrome Ventricular tachycardia Causes of wide QRS complex tachycardia

5 SVT vs VT Clinical history MedicationDrug-induced tachycardia Torsade de pointes Diuretics Digoxin-induced arrhythmia [digoxin] 2ng/l or normal if hypokalemia Age- 35 ys VT (positive predictive value of 85%) Underlying heart diseasePrevious MI 98% VT Pacemakers or ICDIncreased risk of ventricular tachyarrhythmia

6 SVT vs VT Physical examination Physical findings that indicate presence of AV dissociation (cannon A waves, variable-intensity S1,variation in BP unrelated to respiration) if present are useful Termination of WCT in response to maneuvers like Valsalva, carotid sinus pressure, or adenosine is strongly in-favor of SVT but there are well-documented cases of VT responsive to these

7 SVT vs VT ECG criteria: Brugada algorithm Brugada P. Ciculation 1991

8 Step 1

9 Step 2

10 Step 3

11 Step 4: LBBB - type wide QRS complex SVT VT small R wave notching of S wave R wave >40ms fast downslope of S wave no Q wave Q wave > 70ms V1 V6

12 Step 4: RBBB - type wide QRS complex SVT VT V1 V6 or R/S > 1 R/S ratio < 1 QS complex rSR configuration monophasic R wave qR (or Rs) complex

13 Step 4: RBBB morphology

14 Step 4: LBBB morphology

15 Other ECG criteria North - west QRS axis deviation Negative or positive concordance Fusion beats, capture beats Ventriculoatrial conduction with block RBBB morphology with LAD > LBBB morphology with RAD > Previous ECG show MI or previous ECG show that during sinus rhythm, bifascular block is present, which changes in configuration during tachycardia

16 Concordance and Northwest Axis

17 Fusion beat and capture beat

18 Ventriculoatrial conduction with block

19 RBBB morphology with LAD

20 LBBB morphology with RAD

21 Previous MI

22 Previous LBBB

23 Findings favoring SVT Triphasic pattern in V1 and V6 Rabbits ear Previous ECG: Preexistent BBB or preexcitation

24 Triphasic pattern

25 Rabbits ear

26 Wide complex SVT from preexisting RBBB

27 Wide complex SVT from preexisting LBBB

28 VT vs AVRT ECG criteria Brugada P. Ciculation 1991

29 Wide complex SVT from bypass tract

30 Summary : diagnosis evaluation ACC/AHA/ESC guidelines for management of pt with SVT. Circulation 2003

31 Management – Hemodynamic compromise 1.Unstable patient, but still responsible with a discernible BP and/or pulse: - Emergent synchronized cardioversion - If the QRS complex and T wave cannot be distinguished accurately immediate defibrillation 2.Unstable patient, unresponsive or pulseless standard ACLS resusciation algorithms

32 ACLS pulseless arrest algorithm AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Ciurculation 2005

33 Management – Stable hemodynamic 1.VT or WCT of uncertain etiology: Any associated conditions (cardiac ischemia, heart failure, electrolyte abnormalities or drug toxicities) Class I and III antiarrhythmic drugs - Amiodarone: 150mg IV/10mins followed by an infusion of 1mg/min for 6 hours, then 0,5mg/min - Procainamide: 15-18mg/kg infusion over 25-30mins, followed by 1-4mg/min by continuous infusion - Lidocaine: 1-1,5mg/kg IV/2-3mins followed by an infusion of 1-4mg/min Urgent or elective cardioversion

34 Management – Stable hemodynamic 2.SVT Vagal maneuvers: carotid sinus pressure (if no carotid bruits) or Valsava maneuver Adenosine: 6mg over 1-2 seconds. If the initial dose is ineffective, a 12mg dose may be given and repeated once if necessary Calcium channel blocker (Verapamil 2.5 to 5mg IV) or beta blokers (Metoprolol 5 to 10 mg IV) Cardioversion

35 Acute management hemodynamically stable and regular tachycardia ACC/AHA/ESC guidelines for management of pt with SVT. Circulation 2003

36 Recommendation acute management hemodynamically stable and regular tachycardia ACC/AHA/ESC guidelines for management of pt with SVT. Circulation 2003

37 Tachycardia algorithm AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Ciurculation 2005

38 Tachycardia algorithm

39 Thank you for your attention


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