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Interpretation of ECG - Part 1

May 23 | 3:30 PM

Arrhythmias are a typical problem that intensivists face. They are a leading cause of morbidity and lengthen hospital stays. The determination of whether the arrhythmia is supraventricular or ventricular in origin is a critical stage in the evaluation process. The most important tool is a 12-lead electrocardiogram (ECG). Examining a previous ECG can also be beneficial. Dr. Subodh Chaturvedi will explain the crucial wave changes to identify for an accurate diagnosis in this first part of- Interpretation of ECG.

[Music] what if you see this image in your ic [Music] on the monitor everything is fine and suddenly this rhythm shows up on your eyes in your icu monitor is it a vt or a vf or is it an artifact should i give xylocar should i give amudoron should i shock this patient or cardiovert or defibrillate what is the difference exactly i don't know how many joules how many shocks cpr or not epinephrine how how much epinephrine sometimes decisions in medical field are as quick as a baseball or a cricket match the ball is coming in you have to decide within moments what to do and the actions you take in next 20 seconds will decide what will happen to this patient so good evening everyone i am dr subhoot chaturvedhi i am a consultant cardiac and bariatric anesthesiologist in a small town called zindor now it is not that small as such i give anesthesia for bariatric surgeries these days and today i will be discussing about arrhythmias in ic before we move ahead i will give you a couple of disclaimers of my own first of all have no financial disclosure this is completely pro bono but i teach professionally i run a platform called as clinical guruji and we have a website we have apps and all but yeah this is completely these people i mean these metrics people invited me very graciously and i'm honored to to accept and humble to accept this invitation and let's have a good time and let's go home learning something so first disclaimer was there is no nothing financial between us secondly this is going to be an interactive discussion i am i can see your comments and everything but you can listen to me i can't listen to you but i can read your comments so this is going to be an interactive class and we will interact through the chat box so let's have an experiment of chat box you'll see an image and you have to tell me who is this guy [Music] write down just you can write the option abcd who's this guy who is this guy can you identify okay i got an a i got a lot of a's a b also nobody is writing him to be my grandfather of course i don't reply him good good good so this is how we are going to be interactive there is a video like there is video good good good good right so this guy has nothing to do with ecg this is my second disclaimer this guy is wilfredo pareto he was an economist you can find him on wikipedia he gave a very interesting rule the rule is called is 80 20 rule 80 20 means whatever you do whatever you study whatever you read eighty percent of it is useless only twenty percent of what you do or what you study or in in every field of life this rule applies it is called as the twenty eighty rule of wilfred operate or the pareto principle commonly only 80 only 20 of what you study is useless and i will try to teach you only the 20 percent of arrhythmia which will actually come handy in your day to day icu lives i exactly don't know what the segmentation of audience in this class is but i'll try to keep it very basic i try to keep it very simple and action oriented things which we can do if you are expecting that i'll teach all this into a 45 minutes webinar i'm really sorry you'll be saddened to know that nobody can teach ecg in 45 minutes not in 45 minutes not in 450 minutes it takes years but still i'll try to make it worth your time i won't be teaching any fancy tables about difference between svt and vt or is it avrt and av and rt so if there are real pure cardiology guys i'm really really sorry but maybe in some other class in some other lecture we'll do a deliberation of half an hour on that only this class i'll keep two very basics let's see how the response comes then we'll move forward in the next classes so i'll talk about the things that are real that are practical they are applicable in the ic so having said that all my three disclaimers let us move on to the topic itself what is rhythm and what is that now in music we call rhythm as something which goes in a sequence like the people who are into music they will know that tal same way if everything is going normal in your heart conduction if it is r s t p q r s t in a routine normal fashion then it is normal sinus rhythm and if it is disturbed by any reason any means then it is wonderful so if everything is normal and in order it is normal sinus rhythm and if it is not then it is arrhythmia but then what is normal any ideas okay let us go to the simple diagram of first year mbbs we have all seen this diagram this conduction diagram just a moment the rhythm or the impulse it starts from the sinuatrial node then it goes to the av node then it goes to the bundle of his and purkinje fibers and spreads all over the heart and conducts the impulse we all know that if all this is happening sequentially and as is it was intended to be then it is normal sinusoidal i am talking very basic if it is happening as it was supposed to be then it is normal sinusoidal so what should be a normal sinus rhythm it should originate from the sinus node of course it should originate at regular intervals it should occur at a rate of like 60 to 100. it should go through the av node in normal time it shouldn't be slow in conduction it should be conducted normally so let's fire up an icu monitor and this this looks like a sinus rhythm doesn't it yes so how do we identify a sinus rhythm on monitor very easy on ecg it should have isomorphic previous what is isomorphic ache jessie those which look alike all p waves should look similar why because they are all originating from the same place they should occur at regular intervals the pp interval should be constant the pr interval the conduction time should be normal it shouldn't be extended the ps2 qrs should be 1 is 2 1 that means every p should have a qrs and every qrs has to have a p and the rate is between 60 to 100 this fulfills all the criteria hence it is a normal sinus rhythm if you go on and see the p waves are isomorphic regular and one is to one ratio every p has a qrs every qrs has a p and the p waves are at the same distance 0 5 10 it's normal what if something is disturbed from this rhythm let's say if the rate is increased everything else is same just the rate is 130 everything else is the same so is it normal sinus rhythm now no this is arrhythmia what arrhythmia it is it is sinus tachycardia still everything is the same the pp intervals are constant the only thing that has changed is rate and it is normal sinus tachycardia now in this lecture we will go on a certain route map a particular way of teaching in which we learn we won't be learning the rhythms according to their origination or their conduction we will be studying them through a traffic light light method what is traffic light method the rhythms can be of three types some rhythms are where you have to stop everything and just read the question don't do anything else if you are in an ots surgery is going on just hold everything ask the surgeon to stop and first reinvent them some of them are like a little less dangerous you can wait but still you have to do something about it and another set is you can just keep observing them and just keep observing them you can keep you you can keep going with the proceedings just that you have to keep an eye so we will classify the rhythms accordingly every rhythm will show in a particular background the rhythms which are really dangerous they will show in red and so on so let's again start with an icu monitor let's do a warm-up set of chotasa basic test what rhythm is this i would like you to write in the chat box what rhythm is going on write in the chat box what is this rhythm all right don't write down no answers or is there a lag yes this is a sinus rhythm but by the time you wrote sinus rhythm something has changed can somebody write what has changed particularly this thing this one this one this one this one this one what's going on what is this what happened yes it was normal sinus rhythm right right right but what happened what happened to this sinus something abnormal is going on can you notice that can you notice that can you notice this what is wrong exactly not ready cardiacs 80. yes what changed what changed watch closely watch closely i have made big graphics for mobile phones also what went wrong what went wrong just something wrong something wrong somebody writes somebody write it not a f no not a yes missed b somebody somebody wrote misspeak yes arrhythmia apc very good very good very good skipped yes something wrong has happened and there are some ectopic beats this beat is not normal this is an ectopic beat right so what is an ectopic this is this was an ectopic beat what is an ectopic beat an ectopic is something which is not where it is supposed to be something which is not where it is supposed to be the pregnancy should have happened in the uterus it has happened in the fallopian tube it is an ectopic pregnancy so a beat which is originating from somewhere else where it should not have been is an ectopic beat we also call ectopic beats as premature complexes the complexes that arise not from the sinus node but somewhere else we also call these ectopics as vpcs or apcs depending on their origin where they are starting from or we also call them lovingly ventricular ectopic or atrial ectopic so ectopic is what ectopic is an event in an otherwise normal rhythm that happens aberrantly that happens strangely it was not supposed to be there and a beat started for an example now there are like five six beats in this ecg one two three four five six speeds actually which one of them is an ectopic can you write down which one of these beats is an ectopic which number first second third fourth fifth which one is the necromancer just ignore this one ignore this one out of these one this one two three four five which one is an ectopic tell me huh okay which one of them is an ectopic tell me yes everybody is writing the correct answer it is the third beat which is ectopic which ectopic it was is it ventricular ectopic or is it atrial ectopic is it apc or is it vpc can you tell me is it vpc or is it apc right correct third beat is ectopic everybody is correct i got all the answers correct is it apc or is it vpc yeah 5 is also not fifth this one but later yes right so the house is divided ventricular and atrial maybe i will call it ventricular ectopic why is it ventricular how do you say it is vpc only why do you say it is vpc how can you identify a vpc i'll tell you a very simple rule of identifying vpc if you can identify it rather if your nursing staff comes and says sir ectopic ra sir there are ectopic beats then it is vbc apcs are very subtle very innocuous very miserable beats apc's everybody misses vpcs are something which are very visible they are broad complex and they come with a change in spo2 tracing also right so vpcs are broad complex very identifiable they look abnormal apcs look more or less similar so if your nursing staff can identify then it is vpc otherwise it is apc now let us see if you can find an ectopic in this can you can you identify is this an ectopic this was an ectopic this one ectopic ectopic beat ectopic beat this one again this one this one this one this one now how do you identify an atrial ectopic beat an atrial ectopic beat looks just like a normal qrs except that it comes a little earlier and it has a differently shaped period an atrial ectopic exactly like a normal sinus beat except for the p wave and the location right so this is an apc the previous one was vpc how did you identify broad qrs very visible i mean anybody can differentiate that this is a normal and this is an abnormal qrs complex when you come here it is very difficult to differentiate between these two complexes they look alike so atrial ectopics everybody will miss and even you can skip them if even if you don't identify electropics its okay but vpcs need to identify right why you need to identify vpcs because the first golden golden rule i'll give for today just write it somewhere or this lecture will be saved watch it again maybe just write it somewhere be afraid of broad qr estimates all the time all the broad qrs rhythms are bad if it is narrow qrs even if it is svt it is better than a broad qrs vt or something so first golden rule is be afraid of broad qrs system what exactly is broad qrs narrow qrs i'll show you i'll show you in the heart itself so this is our good old heart you know that obviously but still for the sake of it this is your right atrium left atrium right ventricle left ventricle probably somewhere here is the sinus load let me go inside ah somewhere here is the sinus node maybe and what place is this what is this place what is this place can somebody write it down for me what is this place this place can somebody write down what is this in this diagram um the question sensor gives me a second look yeah say we know fine fine fine so let's draw an imaginary line from above the av node and below the av node above the av node everything is supraventricular below the av node or below this line everything is ventricular right everything below this line is ventricular everything above this line is supraventricular so pra and ventricular and between this there is this av node and this av node acts as what i don't know what you people call it but we call it gane kara's bananaki machine i don't know what you call it maybe sugar cane juice making machine i don't know but av node is exactly like a ganache rs varane machine what does gandhi kara's baraniki machine does a round thick sugar cane goes in and a narrowed down pitch a narrowed down gunner comes out this av node does exactly the same thing it works like a machine a small gold round p wave goes in and a narrow qrs comes out of this av node just try to remember it this way the av node is like this machine a round p wave goes in and a narrow urs comes out so all the rhythms which are going through this node are going to be narrow qrs why because this node is acting like this machine and all the rhythms below this line are going to be broad qrs because they are not going through this are you getting me again any rhythm which is going through this part this line will be narrow qrs and anything which is not passing from here will be broad qrs so all your ventricular rhythms will be broad qrs so what are broad qrs rhythms let's say your ventricular rhythms like ventricular tachycardia ventricular fibrillation ventricular ectopics ventricular paste beads pacemaker beads so ventricular ectopics ventricular based beats ventricular tachycardia ventricular fibrillation idioventricular rhythm aibr everything is broad qrs why because it is not passing through the gandhara machine and everything above this whatever it is sinus rhythm sinus sticky cardia atrial tichycardia supraventricular tachycardia junctional tickycardia junctional rhythm everything is narrow why because it has to pass through this machine are we together are we here did you get this did you get this point what i told you everything about this line is everything above this line is supraventricular and narrow qrs and everything below this line is ventricular or broad qrs so you should always be wary of broad qrs rhythm you should worry about vpc why because vpcs can degenerate very quickly the moment you see bpc is going on you have to think of the cause you have to think what's wrong with this patient you have to think what's going on with this patient you have to think of the five edges and the five p's why this patient is throwing up ppcs because if these vpcs continue they will start becoming what what is this these are what is this can somebody write down yes what's that what's that what is this this is a ventricular couplet just say like urdu shear is also called as couplet because it has two sentences there are two vpcs these are couplets so if vpcs are ignored they can become into couplets or even triplets these are triplets three vpcs together how do you identify it as vpc it is very identifiable broad qr is totally different looking than your normal sinus beat anybody can identify vpc in fact the diagnosis is if you can identify then it is vpc only so vpcs are very identifiable if they are in patterns of three then they are triplets if they are in patterns of twos they are couplets so if you ignore couplets for very long what will happen because couplets are occurring because of a reason or did you see when it was simple ectopic they were green now couplets were orange and if these couplets are allowed to occur they will turn into what what is this what is this tell me tell me tell me what is this what rhythm is this the couplets have disintegrated into what and it has become a red rhythm in our traffic light system what is this rhythm tell me write down write down write down what is this rhythm yes it is a vt it is a ventricular tachycardia how did you identify it is broad qrs and regular anything that is a tachycardia and broad qrs and regular always worry about ventricular tachycardia it is a red rhythm it has to be treated immediately something has to be done stop everything ignore other patients and treat this one this is ventricular tachycardia now i'll put a poll for you to write down in chat box you have to tell me what is the first thing you will do choose from these options write down so most of them are defibrillating lignocaine amiodarones epr none of the above do you know what is my answer i agree with this one i i just missed it i just missed it the name so many people are writing exactly correct answers that's so good so good so good wonderful wonderful so next class will be a little upgraded one fine so i will do none of the above i will check the pulse if the patient is stable i will go for medication if the patient is unstable i'll go for something else only two things you need to decide in the icu a can this rhythm kill my patient and b how should i treat it should i give a shock should i give medication if a medication then which one or should i just observe so you have to decide only on two things and what we do instead is it svt with average conduction is it is it something this something that by leave something for cardiologists leave something for ep people all you have to decide is can my patient die because of this rhythm if yes then how should i treat it should i shock him should i give a medication or should i just observe so the first golden rule was you know be afraid of broad qrs complexes the second golden rule is every tachycardia causing hemodynamic instability will be shocked every tachycardia causing hemodynamic instability and the keyword here is not shocked the key word here is causing hemodynamic stability you have to have sufficient reason to believe that the hemodynamic instability is because of tachycardia so every tachycardia causing hemodynamic instability will be shocked you know most many of you are answering the that vitals are okay then we will not shock and if the vitals are bad will shock that's so good but then the key word here is pausing let's see an example this is a patient maybe you can't read the numbers it's 137 by 95. he's a patient in cyanosystem he's having good vitals everything is fine he goes into a tachycardia probably a supraventricular how do you identify superventricular tachycardia it is fast narrow qrs no pv present regular a supraventricular svt from sinus and his bp drops to 78 by 44 he becomes hypotensive he becomes symptomatic he's having palpitations he's having confusions is kind of getting drowsy he needs to be shocked because the tachycardia is causing the instability right and the other thing maybe a patient is in sepsis in your icu already in sinus tachycardia with a bp of 90 by 63 and he goes into atrial fibrillation and his bp drops to 80 by 49 of course there is a there is a hypotension but probably this tachycardia isn't causing the hemodynamic crash he was already bad the tachycardia has just pushed him far maybe you can avoid shocking this question are you getting my point what i'm trying to explain is that you have to have reasonable reasonable cause to believe that the tachycardia was the reason of his hemodynamic instability probably he was very he was way better before the tachycardia so if the tachycardia has caused instability we will shock it if it is a stable tachycardia then we will go for like like uruguay says we'll go for delty as it and yes if the patient is already unstable and in vtec we will definitely give shock this is for the things which happen in front of us if the patient is like unstable and he is throwing a bt we have to believe that this instability is because of the beauty itself right so even svt has to be shocked if it is causing hemodynamic unstability so every tachycardia that is causing unstability will be shocked but then the key word is unstability being caused by the tissue right i i hope i could get the point through adenosine yes yes yes everything can be done what is the disadvantage of shocking this patient sir no there is no disadvantage of shocking this patient but maybe there is no added advantage of shocking this patient we can shop i have seen people shocking bradycardias i have seen people shocking air system so there is no harm in shocking this patient but remember every shock causes myocardial dysfunction also right shocked everything comes with the cost in medicine there are trade-offs there is no solution you have to exchange something right so let's go further if it is a pulseless vt or a ventricular fibrillation it has to be defibrillated if it is stable vt or maybe if it is svt then svt needs to be cardioverted this cardioversion versus defibrillation is kind of beyond the scope of this lecture but if it is supraventricular tachycardia or regular rhythm then it needs to be cardioverted what is cardioversion the same defibrillator it pinpoints the qrs complexes and gives the shock exactly at that pinpoint so that is called as cardioversion and defibrillation is you just give a shock don't think it where the shock is exactly falling right if you want to cardiovert maybe you can start with 100 joules so if it is a pulses vt or if it is a vf it needs to be defibrillated if it is stable vt or svt it needs to be just a moment it needs to be shocked right what if we don't shock a vt what will happen i mean we didn't shock a couplet and eventually it went it landed into a ventricular tachycardia but even if we don't even shock of integrated tachycardia it will further degenerate into a worse rhythm and what is this worst rhythm of course you can tell me but i would still be here synchronized synchronized definitely i'll still be amused if you write me the answer what is this rhythm into which this vt has disintegrated what is the rhythm write down [Music] yes if we don't shock a vt it will go into ventricular fibrillation push d yes it is a ventricular fibrillation ventricular fibrillation can be coarse vf which looks more or less like a vt just more irregular more abnormal or it could be a very fine vf where it is very small waves of ventricular accumulation but eventually a vt untreated most of the times goes into fibrillation and again this ventricular fibrillation is a red rhythm stop everything and treat the patient and there is no pulse in ventricular calculation so if you have vf on monitor what will you do what is your next step write down you have vf1 monitor what is your next step write down choose your options yes now everybody is right we will defibrillate the ventricular fibrillation of course we cannot cardioverted amiodarone no first and foremost thing we will defibrillate a patient of vf and yes vf will not have a pulse so there is no point in checking for pulse so what is the treatment of anterior fibrillation you have to defibrillate defibrillate with how much joules either 200 or 360. 200 in biphasic 316 monophasic no point in remembering the maximum joules on your machine you have to give these forget everything what is the maximum number of your on your machine just shock the fibrillation with that much so ventricular fibrillation has to be treated with either 200 or 360 of course depending on if it is more or basic or if it is biophasic just choose the highest number on your machine and give a shock what else what else you do we need to do cpr shock cpr what else shock cpr epinephrine how much epinephrine some people call it adrenaline aha people call it epinephrine how much one milligram every three to five minutes so now since we have gone through the broad qr sticky cardios summit now here now we have gone through the broad qr sticking ideas let's have a small practice this is a wide qrs tachycardia the rate i have calculated for you it is approximately 110 qrs is wide pulse is present bp is 110 by 80 what is your drug of choice will you shock this patient of course i won't shock this patient the bp is normal pulse is present what is your drug of choice a mule ignore shock choose commuter only no cane or shock broad qrs pulse present bp is 110 by 80 what will you give what will you give in this patient no it is not the idea broad qrs with pulse now again another take-home point acls is good but acls is not gospel [Music] acls was meant for people who were paramedics who saw a patient uh who is like 70 years old and had chest pain and then fell down and probably had a vtvf acls works there in a hospital icu in an emergency unit in an er there are so many things happening and it is not always good to believe that every broad qrs tachycardia is ventricular tachycardia so this sticky cardia is broadcast but then it is not that fast what is the rate uh maybe one big box two big box three big box 150 what is the rate exactly have you seen vts of 150 no it was not 150 it was 110 the rate was 110. so have you seen a vt of heart rate 110 no and the qrs is too broad it is not broad like vt it is too broad it is almost like 200 milliseconds so yes it is tachycardia just because it is 110 but it is not vt the qrs is too broad to be a vp think of other things think of things like hyperkalemia presents with bradycardia hyperkinemia presence with tall t waves but so many times hyperkalemia too much of potassium presents with really really broad qrs complexes with a rate of maybe more than 100 maybe less than 100 but if it is too broad and not too fast think about something else probably hyperkalemia and what will be your drug of choice now not hypo are we pulse was present yes yes yes vt can have a pulse but still my point is it is too broad to be a vt and it is too slow to be a vt vts are usually 200 yes electrolyte what will be your drug of choice in hyperkalemia tell me tell me tell me tell me before i show you hyper hyper of course no not mg what is the drug of choice yes calcium gluconate and soda bicarbonate artwork of choices will be sodium sodium bicarbonate and calcium gluconate but now somebody will ask me sir what if it was eating we don't know i mean just by being too broad or a little slow you cannot say but then what is the harm in giving soda y carbon calcium gluconate to somebody what is the worst that can happen with those two maybe his sodium will increase a little maybe his bicarb will increase a little maybe co2 will increase a little maybe his bones will become a little stronger with your calcium even if you give calcium gluconate and soda bicarb to somebody with bt there is not much of a harm per se like i said it is against the guidelines but then acls is not everything across doesn't treat patients absolutely acls doesn't have a 100 result so yes we can give these things again think with your own brain so every broad complex tachycardia is not vt that is my third goodal golden rule for the day sometimes it can be hyperkalemia also give calcium and soda so if you just got these two three things right beware of broad qrss every broad qrs is not vt and every rhythm which is causing hemodynamic instability has to be shocked if you just got home these two three things right my job for the day is done this was the first milestone in this class do you think this class has been up to your expectations write good or bad in the chat box then we will move on to more orange rhythms if you think this class has been up to your expectations you can write good or bad i don't know any of you your choice then we will move forward [Music] so far so good actually let's move on so let's move on to a few more orange rhythms we saw that ventricular couplets ventricular ectopics can degenerate into ventricular tachycardia what can atrial ectopics degenerate into this is atrial ectopic how do you identify it is an 8 electrophilic it looks more or less the same as the previous qrs complex of a normal sinus beat it is just a little early it's just a little premature and there is a compensatory pause let's not go there this is an apc what if we leave apc is b what will happen to apcs where will it go the apc's will land up into what the apc's will turn into something different and i tell you this is not vt or vfr don't write that these are all narrow qrs's but the p waves have gone and this rhythm has become irregular and irregularly irregular what is this rhythm tell me tell me tell me but don't don't tell me i'll tell you this is atrial fibrillation how do you identify an atrial fibrillation it is narrow qrs irregular p wave absent hey by the way i i have made a made up pdf because see this this this lecture was already going way beyond the time we planned so i have made a small pdf you can you can you can uh you can you can ask for ask for this pdf on my whatsapp it will be answered by automatic chatbot you can just ask for this pdf i have made a chart of that let's go so atrial fibrillation is narrow qrs and no pva present irregularly irregular what are the most common arrhythmias atrial fibrillation which one is the most common indian in icu tell me is it atrial fibrillation well before you write down i'll tell you the most common arrhythmia in icu is not atrial fibrillation but it is sinus tachycardia it is anatomy ultimately the rate is different what are the most common causes of sinus tachycardia in an icu the patient might be hypovolemic the patient might be in pain the patient might be having hypercarbia or the patient is on ventilator and awakened fighting with the ventilator so these are the the technically the most common rhythmia is sinus tachycardia but practically when you actually talk about arrhythmias atrial fibrillation is the most common area in the icu you should be able to recognize it by irregularly irregular pulse narrow qrs previous absent if the patient is unstable in atrial fibrillation will have to shock him if he is stable then we can think about amiodarone 150 mg 100 ml over 20 minutes so atrial fibrillation was another orange rhythm it could turn to red if the bp falls but most of the time it is originally it is the most common arrhythmia then we can think about another arrhythmia which is orange it is not that common because it again quickly degenerates into atrial fibrillation but yes still atrial flutter is something we should know about how do you identify atrial flutter it is narrow qrs regular but p waves are present this narrow qrs it is regular all the qrs complexes are regular interval but and p waves are present but multiple p waves are present like one two three previous here two p waves and one qrs two p v s one qrs so there is a two is two one three is two one four is two one atrial flutter is a regular rhythm despite being atrial it is regular but narrow qrs and multiple p waves present the ps2 qrs is not is not in 1 is 2 1 ratio the p waves are multiple few more supraventricular enemies these two again how do we differentiate they look all the same this one is narrow qrs regular very fast but p wave is absent this is a combo of p waiver this is probably the t wave of previous qrs complex in this one there is a p wave there is a qrs complex and there is a t wave both are supraventricular but one is svt and the other one is sinus tachycardia how do we differentiate in sinus tachycardia there is a p wave in front of every qrs complex in supraventricular tachycardia there is no p wave these are just the t waves of the previous qrs complexes can you differentiate the two i think the size is big enough to differentiate can you differentiate yeah sawtooth is seen in atrial fibrillator so supraventricular tachycardia is very fast regular narrow qrs and no p waves visible sinus tachycardia is again fast regular narrow qrs but p waves are visible and one is to one one more difference supra ventricular tachycardia most of the time goes way beyond 180 200 to 220 svts are usually 200. sinus tachycardia usually in adults doesn't go beyond 140 150 sinus sticky cardias are in the range of 140 150 but if you watch us if you if you get to see a tachycardia that is 200 plus most of the time it is supraventricular taking idea again i will not go into avrt and av and rt maybe maybe five percent people will be angry with me in this workshop but still most of the people can do with this if the rate is more than 200 or 180 it is all likelihood svt what is your treatment ready no see if it is in the range of 140 150 p wave present piece to qrs 1 is 2 1 then most likely it is sinus technical idea what is the treatment treat the cause could be pain could be hypovolemia could be whatever ventilator related problems right in supraventricular tachycardia if there is no hemodynamic appeal just wait and watch so i have shown you enough rhythms now let's have some practice again yeah i i'll number i'll give the number what is this rhythm write down what is this write down write down right now in this part i won't do anything just you will keep answering what is the rhythm vt or vf yes it is qrs irregular irregular y irregular broad qrs irregular what is this rhythm now it is change ah we have change next what is this rhythm this one this one this one vfo this one there are qrs complexes they are at regular intervals or irregular intervals there are p waves no there are no p waves they are fibrillation waves probably it is atrial fibrillation what do you say could be never know maybe watch this lecture again what is this rhythm what is this rhythm this somebody will tell me good okay there is a 30 seconds lag between when i see and when i get the answer what is this one this one no this is not idiom integral this one this one this one somebody write down yes it is bt yes it is vt somebody write a better answer this is vt yeah but what kind of vt this is torsa now i mean i belong to a madhya pradesh background i learned tangareshi in college but i mean we used to call it torsadis the point is but the french call it torsada right or torsade point is whatever you call it the meaning is twisting of points like you take a towel and twist it like this what we call in india if you take a towel and just twist it it is just like that we have taken a regular ventricular techie guardia and just natured it this is sour status the point is the treatment is magnesium and whatever ultimately it is unstable you have to give shock when it is stable then you think we have to give magnesium and we have to give whatever right what is this rhythm the last rhythm what is this what is this tell me tell me tell me somebody tell me what is this somebody tell me what is this then i'll tell you a story what is this what is this one right everybody is writing is study and everybody is right and everybody is wrong why this is not a stone or a system as they call it this is flat line we don't know if it is stole or not we don't know why we need to check so whenever you see a flat line again you can take it as a golden rule whenever you see a flat line on your monitor do two things a check the leads check the leads of ecg if they are there or not if they are removed or not secondly increase the gain in amplitude of this thing increase the amplitude and check the leads so many times in a very big hospital i cannot name it on camera in a very big big big hospital you can't imagine i have seen people being given cprs and chops just because an ecg lead was missing so two things we'll do one is we'll check the ecg leads and secondly we will increase the gain increase the amplitude increase the size of it there is a button in every monitor they call it by different names why because sometimes it can be a very fine ventricular fibrillation which is showing up as a flat line if you remember i had shown you a fine ventricular fibrillation also just below the course ventricular fibrillation so if it is a fine ventricular fibrillation it becomes a shockable rhythm if it is if it is asystely it is just cpr and epinephrine so the treatment is totally 180 degrees so you increase the gain increase the amplitude and then check if it is still a flat line lead is in place even after increasing the gain it is still flat line then it is a sisterly and you have to shock or not not shock if you have to give epinephrine and you have to cpr cpr epinephrine cpr if you return in a flat line if by increasing the gain you realize it is vf then it is shock epinephrine cpr right so let's just summarize the three step process of management we'll see if the rhythm is slow or it or is it fast we'll see if the rhythm is stable or unstable and we'll see if the qrs's are broad or narrow if the rhythm is slow then it is bradycardia is it a block i don't know if it is a block then maybe we will give atropine maybe we will give a dopamine drip if atropine is not working maybe we'll use pacemaker this was written for the ot scenarios then we'll look for the cause what is the cause of this radicardia we'll check if the rhythm is stable or unstable is the rhythm cause of instability we will jump to cardioversion and defibrillation early in the treatment then if the rhythm is stable then we will think maybe we should give medication which one amiodarone lignocaine whatever we'll see if the rhythm is broad or narrow is it too broad and less tacky think about metabolic causes think about hyperkalemia we'll try soda by carbon calcium is it a stable vt maybe we'll think about a mudroom or maybe xylocaine or maybe we can think about amiodarone if it is supraventricular tachycardia we can give adenosine maybe we can think about deltiasin so i guess that is all for today i guess my time is way beyond over i was supposed to go up to like 45 minutes they said you can go up to one hour so my one hour is over from nine zero five to ten zero five so that is all for today uh if you want five ten minutes more than you can right continue i have two more slides otherwise we can wind up so the session is amazing enough you can continue for sure so if the organizers permit and the people want then maybe i can continue for like five minutes or maybe we can wind it up right now yeah you can uh you can continue the presentation so can i continue for five minutes yes yes yes fine fine fine fine right so five more minutes in these five minutes because i haven't taught you uh uh i haven't taught you bradycardias so very quickly i'll show you six bradycardias in two slides and maybe that will do for your ic these are three bradycardias all i mean technically it is 65 or this is 62 but then they are all practically bradycardias what is the difference this one is sinus brady this one is first degree heart block and this one is junctional blood sinus brady why because everything is sinus except for the rate there is p is to qrs one is to one all are at regular regular intervals and narrow qrs and everything is like everything is fine except for the rate being less than 60 this one is this one is first degree hard drop why everything is normal except for the pr interval except for the pr interval which is too broad this one pr interval is normal this one pr interval is too broad they all look the same this one again bradycardia but no p wave visible look very closely bradycardia with no p wave bradycardia with long pr interval bradycardia absolutely normal except for the rate all these three bradycardias are usually very stable they don't need to be treated you have just to wait and watch and observe sinus first degree junctional bijunctional no p wave y first degree long pr y sinus everything normal except for rate these are all bradycardias but stable ready cardias you don't need to even give it to me if the bp is good and everything is fine the patient is stable it's talking to you don't give a trophy these are all okay problem is the next three which are the av nodal blocks type two type two pinky back and more bits and complete hard block or third degree again i'll explain i won't go into detail of that the pr increases increases and the beat has dropped no what is the point if i repeat the same things if the bradycardias have clumping of qrs complexes grouping clumping three are together then three are together then three are together three are together then three are together i am not even looking at the pr interval if there is a bradycardia and p waves are more than qrs of course because it is a block and there is grouping of qrs complexes it is type two let's not going to type to winky back hacky moby described to him no just if there is grouping of qrs complexes along with bradycardia then it is second degree heartburn and second degree heart block is bad enough it has to be treated you have to involve a cardiologist you have to tell him that he might need basing how do you identify this one this is a bradycardia which is usually unstable the patient usually falls in the washroom he is unconscious he is an old old guy or an old lady who comes with bradycardia with bp is usually increased the heart rate is typically 30 to 40 why 30 to 40 because the ventricular scape rhythm is 30 to 40. usually it is broad complex again i am saying usually there are exceptions to everything what i have taught you so far but then usually 20 percent of what wilfred pareto said if there is grouping of qrs complexes it is type 2 it is second degree heart block it has to be treated if the heart rate is like 30 to 40 it is broad qrs in regular bradycardia broad qrs regular bradycardia 30 to 40. most likely it is complete hard block has to be treated pumping of qrs second degree heart block broad qrs regular bradycardia regular broad qrs 30 to 40 heart rate this complete heart block again has to be treated involve a cardiologist what you can do in an icu you can maybe give a trophy in 0.5 mg stat or you can try epinephrine infusion or dopamine infusion not talking about boluses dopamine infusion or epinephrine confusion or you can try pacing transcutaneous through uh your defibrillator facing pads or there is one more good thing how to do temporary facing in icu there is this seven french sheath which cardiologist people use or even even anesthesia people use in cardiac or pa sheets so if you have a seven seven and a half print sheath you can insert it through the jugular and put the pacing lead directly from there you don't need to wait for a cardiologist to come and take the patient into cath lab if the patient is seriously seriously unstable maybe what you can do is just put a jugular line just put this sheath in jupiter and pass a pacing lead connect it to the pacemaker check for the complexes the moment it will touch the right ventricle just hold it there and it will start facing course i mean the stunts in this program are done by experts but still that can be done we used to do that in metro hospital delhi i worked as an icu registrar there so we used to do that we put a jugular sheath seven and a half inch sheath if the patient is goes into bradycardias we can use it for pacing if the patient goes into lv failure we can use it for a pa calculator so that is sachimuchi all for today if you like the class you can write happy in the chat box and you have already got my number it is an automatic chat box if you call it my assistant will pick it up you can write whatever you i mean you can ask for the pdf notes on that whatsapp so that's all for today if you like the lecture then maybe sometime in near future or far future we'll have another class maybe on schema maybe on a particular arrhythmia or maybe some other aspect of ecg that's all for today if you have any questions i'll be more than happy to answer them thank you for your patient listening as such you cannot say anything right now [Music] yeah thank you dr sabo that was an amazing session today and we had some wonderful insights regarding a lot of topics like very basic topics we talked about the golden rules of ecg and a very basic and simple comparison of av node and gandhi karaska machine also it was amazing so thank you and i would request uh the viewers or to put their questions in the comment box if any and we can take them in next one minute yeah i'm there hmm questions i can answer you can put the zoom chat box also and not zoom chat box uh they will come in the comments now yes yes uh you can see that in the comments uh right right right thanks a lot happy happy happy happy two happy happy happy happy happy pdf i cannot send you you can that's a chatbot you can you can just type hello on that chatbot and it will give you the pdf [Music] [Music] can we get the recording is the recording will be in the app itself could you please help with ventricular escape rhythm ventricular escape with them what is [Music] recommended only when it is sinus system no not in cyanosystem in a regular rhythm you can do cardioversion otherwise defibrillate all the fibulations need to be defibrillated defibrillated take usually in arrhythmia you are told to check saturation electrolytes hypovolemia results etc but if it is unstable you have to shock all right when to give dopamine dopamine that is a totally different lecture i know drops and vessel pressures i'll have a big webinar on that may be in july i am planning for that that will be a big one uh usually in arizona role of beta blocker when to use in arithmetic not really therefore more for opd treatments cardioversion weekly rn is there any maximum limit how many times we can shock the patient no till the patient get backs or or dies yes recording will be available ah ventricular escape rhythm what is ventricular escape rhythm i'll explain uh see we say that sinus node is the pacemaker of the heart sinus node is not the only pacemaker of the heart the whole conduction system can act as a pacemaker the av node can act as a pacemaker the uh the ventricular purkinje fibers can act as a pacemaker but the system is such that the sinus node has the maximum rate 60 200 av node has a little less and ventricle has a little lesser so ventricle beats at 35 to 40 av node beats at a little higher and sinus beats at 6200 so what if sinus is not working what if av node has stopped all the conduction the ventricle will start beating by itself the ventricle will realize that there is no impulse coming from upstairs and ventricle will beat by itself that will be an escape rhythm and it will always be at a rate of 35 to 40. sometimes it is junctional escape rhythm also but let's not go there the perfusion will approach the perfusion just to observe nothing nothing else inverted p wave when it is seen what about p a t uh what about p a t what about p a t inverted p waves inverted p wave i'll try to explain usually p wave comes from sinus node sinus node to av node sinus node to av node what if the impulse is originating near to the av node sometimes somewhere near the junction then what will you do what will happen if it is occurring near the junction it will conduct downstairs to the ventricles just like a normal beat through the av node narrow qrs and at the same time it will go upstairs in the atria but then since it is going in the reverse direction due to the flow of current it will be marked as a negative pvf so junctional beads or some atrial beads are marked as negative previous in the ecg release like i said 45 minutes is a small time i have taken one hour and i have taught nothing how to differentiate matte and a fib mat has p wave present but all the p waves look different atrial fibrillation there is no p wave present there is just a wave of fibrillation it looks more like sea waves there is no visible pivot mat is having pv but all the p waves are different or coach very nice lecture sir recording is in this app only uh these people will tell wpw syndrome has white you are coming random questions versus which is better nothing is better aha people uh for one guideline say i'm your own is good then next guideline they say lingo can be used deeper fusion just wait and watch how to diagnose the vowel syndrome in wp synthetic how to get pdf just send me a whatsapp on this number how to calculate rate in ventricular techniques how to calculate rate is very easy one box 300 two box 150 three box hundred i guess that's that should be good enough for the day thank you so much thank you dr it was a pleasure having you looking forward to your next session as well [Music] thank you everyone thank you


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