ECG Guru - Instructor Resources

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Instructors' Collection ECG of the WEEK, April 12, 2015 ___ Paroxysmal Supraventricular Tachycardia

Sun, 04/12/2015 - 15:59 -- Dawn

This ECG is from a man in his 60's who is experiencing chest discomfort and palpitations.  The onset of the rapid heart rate and the symptoms was sudden, while he was at rest.  The rate did not slow when he was placed on oxygen, given IV fluids, and rested further. The rate is 177 / min.  

The rhythm is AV nodal reentry tachycardia (AVNRT), which is one of the rhythms that falls into the category of paroxysmal supraventricular tachycardia (PSVT).We can see signs of retrograde P waves in some leads (II, III, aVF, V1).  AVNRT is caused by a reentry circuit in the AV node.

 

Some instructors teach students that sinus tach is approximately 100-150 per minute, and atrial tach is usually 150-250 per minute.  If students only learn about differentiating these two rhythms by the rate difference, it will cause later problems.  Of course, there is actually an overlap in rates between the two rhythms.  For example, a febrile, dehydrated infant could easily reach this rate and be in sinus rhythm.  A young, healthy person on a treadmill could, too.  Clues to the ectopic origin of this rhythm are:  sudden onset (unfortunately, not witnessed here), regular rhythm with unwaivering rate, and the patient's situation (symptoms while at rest, no obvious reason for sinus tach).  Of course, we need to teach to the level of our students' abilities.  Consider whether they just memorizing rhythms criteria now, or are they learning about re-entry?

There are many different mechanisms of supraventricular tachycardia, and they differ on an electrophysiologic basis.  Depending upon the level of your students, you will have to decide how much detail to teach.  There are many resources on this site, including the ECG Archives, Ask the Expert, Jason's Blog, and Favorite Sites that will help you if you want to go into more detail.  For many health care providers, the entire category of "PSVT" is treated the same initially, and there is no need to differentiate the types of PSVT.


ECG Basics: Sinus Bradycardia With A Premature Atrial Contraction

Mon, 04/13/2015 - 23:45 -- Dawn

This strip shows an underlying sinus bradycardia with a rate less than 40/min.  There is one "premature" beat, which can be considered to be ectopic, because it interrupts an otherwise regular rhythm.  The interesting thing is that the premature beat is not terribly early - it is about 740 ms from the previous beat.  If all the beats were spaced like this, the heart rate would be about 84/min.  There is probably an element of "escape" here, in that the ectopic beat is able to express itself due to the slow rate.  A faster sinus rate would override this ectopic focus.  So, we could view this early beat as a help, rather than a problem.  The most important consideration here is to address the cause of the bradycardia, and treat appropriately. 

Are You New to Laddergrams?

Fri, 02/20/2015 - 22:34 -- Dawn

A laddergram is a diagram of conduction through the heart, presented in a minimum of three tiers, one for the atria, one for the AV junction, and one for the ventricles.  Laddergrams are very useful for presenting and testing your theory of a dysrhythmia.  Instructors often use them to illustrate complex dysrhythmia mechanisms.  

If you don't yet have experience in using laddergrams, go to this LINK to find a short PowerPoint presentation that will give you the basics to get started.  Be careful - it can be a bit addicting to construct laddergrams, like working a puzzle.  If you want to use laddergrams to teach your students, this PowerPoint presentation can help you introduce them to the concept.  

Our thanks to Jason Roediger, ECG Guru and dysrhythmia expert, for the laddergram depicted here, and the many LADDERGRAMS featured in his blog posts on this site  to see the discussion accompanying this ECG, go to this LINK  (Warning: this is an ECG Challenge, which is advanced material)  

 “For another step-by-step review from Dr. Ken Grauer on How to Draw a Laddergram - Please check out Dr. Ken Grauer’s ECG Blog #69 - GO TO - http://tinyurl.com/KG-Blog-69

 

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