Ecgs for discussion in intensive care.pptx

Interesting ecgs for discussion

1. ECGs for Discussion Dr K Swarna Deepak

2. 2 S.NO INTERVAL/SEGMENT DURATION SMALL BOXES 1 PR INTERVAL 0.12-0.20 SEC 3-5. 2 QRS INTERVAL <0.12 SEC <3. 3 QT INTERVAL CORRECTED 0.35-0.44 SEC

3. 3

4. SINUS RYTHM 4

5. SINUS BRADYCARDIA 5

6. SINUS TACHYCARDIA 6

7. ATRIAL FIBRILLATION 7

8. MULTIFOCAL ATRIAL TACHY CARDIA 8

9. ATRIAL FLUTTER 9

10. SUPRA VENTRICULAR TACHYCARDIA 10

11. PAROXYSMAL SVT 11

12. METHOD OF CALUCULATING IN IRREGULAR HEARTRATE 12

13. WPW 13

14. JUNCTIONAL RYHTHM 14

15. IDIOVENTRICULAR RHYTM 15

16. PREMATURE VENTRICULAR CONTRACTION 16

17. MONOMORPHIC PVC 17

18. POLYMORPHIC PVC 18

19. VENTRICULAR BIGEMINY 19

20. VENTRICULAR TRIGEMINY 20

21. VENTRICULAR QUADRIGEMINY 21

22. COUPLETS 22

23. ASYSTOLE 23

24. PULSELESS ELECTRICAL ACTIVITY 24

25. MONOMORPHIC VT 25

26. POLYMORPHIC VT 26

27. TORSADES DE POINTES 27

28. VENTRICULAR FIBRILLATION 28

29. FIRST DEGREE AV BLOCK 29

30. 2DEGREE-MOBITZ TYPE 1 30

31. 2 DEGREE MOBITZ TYPE 2 31

32. 3 DEGREE AV BLOCK 32

33. BUNDLE BRANCH BLOCKS W i ll ia M M a rr o W LBBB RBBB 33

34. LBBB 34

35. LBBB 35

36. RBBB 36

37. Q 1 ECG 20 years old female presenting with palpitations and pre syncope

38. ATRIAL FIBRILLATION WITH WPW Main Abnormalities: Irregularly irregular broad complex tachycardia Extremely rapid ventricular rates — up to 300 bpm in places (RR intervals as short as 200ms or 1 large square) Beat-to-beat variability in the QRS morphology, with subtle variation in QRS width Explanation of ECG Findings: Irregularly irregular rhythm is consistent with  atrial fibrillation There is a left bundle branch block morphology to the QRS complexes However, the ventricular rate is far too rapid for this to be simply AF with LBBB The rates of 250-300 bpm and the variability in QRS complex morphology indicate the existence of an accessory pathway between the atria and ventricles Diagnosis: These findings indicate  atrial fibrillation in the context of Wolff-Parkinson-White syndrome

39. ECG – 2 A 28 years old female, with a history of eating disorder, presenting with syncope

40. R ON T - TORSADES Main Abnormalities The first half of the ECG shows sinus rhythm with prominent U waves and a long QU interval (520ms). An  atrial ectopic beat kicks off a run of  Torsades de Pointes by landing on the T/U wave during the vulnerable phase of repolarisation and causing “R on T” (or “R on U”) phenomenon. The combination of – Atrial ectopy , Prominent U waves, Long QU interval Torsades de Pointes, is strongly suggestive of severe hypokalaemia .

41. Q 3 ECG 20 years old male presenting with altered sensorium , hypotension and seizures

42. TRICYCLIC ANTIDEPRESSANT OVERDOSE Main Abnormalities Broad complex tachycardia, rate ~ 130 bpm The rhythm is likely sinus tachycardia with a 1st degree AV block — note the “camel hump” appearance to the T waves indicating a hidden P wave Interventricular conduction delay (QRS duration > 100ms, not typical LBBB / RBBB morphology) Right axis deviation Secondary R’ wave in aVR > 3 mm In the context of seizures and hypotension, the combination of QRS broadening > 100 ms R’ wave in aVR > 3 mm … is highly suggestive of poisoning with a sodium-channel blocking agent — e.g. tricyclic antidepressant. The sinus tachycardia may be due to the anticholinergic effects of the TCA.

43. Q 4 ECG A 35 years old male presents with chest pain and diaphoresis. The first ECG was taken at the time of presentation. The second ECG was taken 25 minutes later when the chest pain subsided.

44. ANTEROLATERAL STEMI / WELLENS SYNDROME FIRST ECG : ST elevation in V2-5 and aVL Reciprocal ST depression in III and aVF Pathological Q waves in V2-3 Hyperacute T waves in V2-4 and I SECOND ECG : There is transient improvement in the ST changes, with development of biphasic T waves in V2-3. This pattern of T wave changes in V2-3 is known as  Wellens syndrome and indicates  reperfusion  of a previously occluded LAD artery. The implication of this ECG pattern is that there is an underlying critical LAD stenosis that requires emergent reperfusion, ideally via percutaneous coronary intervention.

45. Q 5 ECG 65 years old female, past history of mastectomy, presenting with dyspnea and shock state

46. PERICARDIAL TAMPONADE Main Abnormalities Sinus tachycardia Low QRS voltages — Multiple limb lead QRS complexes < 5 mm in amplitude. Electrical alternans — There is a beat-to-beat variation in the QRS complex height. Taller complexes alternate with shorter ones The triad of tachycardia, low QRS voltages and electrical alternans is extremely suspicious for massive pericardial effusion.

47. ECG 6 43 years old male presenting with syncope and hypotension

48. COMPLETE HEART BLOCK Normal P waves (upright in II, inverted in aVR ) are present at a rate of ~ 85 bpm . There is no relationship between the P waves and QRS complexes — the PR intervals vary randomly. A ventricular escape rhythm is present at ~ 36 bpm .

49. 7 ECG 40 years old male presenting with palpitations and dizziness

50. VENTRICULAR TACHYCARDIA Abnormalities This ECG shows a regular broad complex tachycardia with an RSR’ pattern in V1. On closer inspection, the ECG demonstrates some classic features of  ventricular tachycardia : Northwest axis — QRS is positive in aVR , negative in I and aVF The  taller left rabbit ear  sign — There is an atypical RBBB pattern in V1, where the left “rabbit ear” is taller than the right Negative QRS complex (R/S ratio < 1) in V6 These findings indicate VT rather than SVT with aberrancy.

51. 8 ECG 80 years old female with co- morbids including DM / HTN / CCF / Osteoarthritis, presenting with generalized dullness

52. HYPERKALEMIA Main Abnormalities Bizarre appearing complexes Marked T wave peaking in V2-6. Gross QRS prolongation (~200 ms) Some leads (I, aVR ) are starting to take on a sine wave appearance Bizarre complexes Sine wave appearance

53. 9 ECG 85 years old male presenting with nausea, vomiting and visual disturbance. Looks dehydrated clinically

54. DIGOXIN TOXICITY Main Abnormalities Atrial tachycardia, with regular P waves visible at ~ 160 bpm (many of the P waves are hidden within T waves and VEBs) Evidence of high-grade AV block — there is a 4:1 conduction ratio between P waves and QRS complexes, with a QRS rate of ~ 40 bpm Frequent ventricular ectopic beats occurring in a pattern of ventricular bigeminy Alternating LBBB and RBBB morphology , with the conducted QRS complexes demonstrating RBBB morphology (RSR’ in V1) and the VEBs demonstrating LBBB morphology (dominant S wave in V1) The combination of… Atrial tachycardia Frequent ventricular ectopic beats High-grade AV block

55. 10 ECG

56. Wellens Syndrome is a clinical syndrome characterised by biphasic or deeply inverted T waves in V2-3, plus a history of recent chest pain now resolved. It is highly specific for critical stenosis of the left anterior descending artery (LAD).

57. 11 ECG

58. Bidirectional ventricular tachycardia (BVT) is a rare ventricular dysrhythmia characterized by a beat-to-beat alternation of the frontal QRS axis. It is most commonly associated with severe digoxin toxicity.

59. 12 ECG

60. ECG showing Acute LBBB with Chapmans Sign S/O Acute MI with prolonged QTc.CHAPMAN's sign is used to diagnose an acute myocardial infarction in the setting of a left bundle branch block and consists of a notch in the upslope of the R wave in lead I, aVL or V6. This has a low sensitivity, but a specificity of about 90%

61. 71 THANK YOU for patient listening……