ECG Guru - Instructor Resources

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Instructors' Collection ECG of the WEEK, March 19, 2015 __ Ventricular Tachycardia

Thu, 03/19/2015 - 16:42 -- Dawn

This wide-complex tachycardia is ventricular tachycardia.  Along with the wide QRS and the fast rate, features which favor a diagnosis of VT over BBB include:  backwards (extreme right) QRS axis, negative QRS in V6, and an apparently monophasic QRS in V1, as opposed to the rSR' pattern of right bundle branch block. 
Remember, ALL wide-QRS tachycardias should be treated as V Tach until proven otherwise, as it is a life-threatening arrhythmia.  Factors which lower cardiac output during V Tach include:  Fast rate, wide QRS, and lack of P wave preceding the QRS.  The sudden severe lowering of perfusion that usually accompanies V Tach can lead to rapid deterioraton and ventricular fibrillation.

For discussions by Jason Roediger (ECG GURU extroidonairre) on recognizing ventricular tachycardia, go to this LINK, and this LINK.

ECG Challenge: Grouped Beating - Double Tachycardia

Sun, 01/25/2015 - 18:42 -- Dawn

This very interesting set of strips was donated to the ECG Guru by Arnel Carmona, well-known to many of you as the Administrator of the blog, "ECG Rhythms" and the FB page by the same name.  He is a frequent contributer to the FB page, "EKG Club", and is an ECG Guru!  This set of strips was previously posted to his blog and to the EKG Club.  In case you haven't already seen it, we will withhold the interpretation for now to give everyone a chance to comment.  In one week, we will post the interpretation.

SEE THE INTERPRETATION AT THIS LINK

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Can Atrial Fibrillation be regular?

This strip is from a pt admitted for UTI.

This cropped lead II strip is from several hours of saved data and specifically posted in order and not necessarily in chronology to highlight a point.

1 - You can see a regular narrow complex tachycardia (NCT) at a rate of about 140’s. How will you read it? SVT? Atrial flutter? AF with RVR? ST with P waves buried in the T waves?

2 - There is still a regular NCT but there is a slowing with no discernible P waves. So AF RVR?

3- The same regular NCT but you can see  regularly-irregular QRS activity. Isn’t it that AF should be irregular and will not show any regularity?

4 - There are groups of 2 QRS with same R to R intervals. It is called GROUP BEATING.

5- There is a regular RR interval at a rate of about 70's with no discernible P waves. REGULARIZED AF?

A few interesting things the strip revealed:

1. The fastest rate was about 140's and the regularized rate was about 70's.

2. There is group beating. For beginners, it is hard to see the group beating but probably as you mature or, as you get so crazy and obsessed in looking at strips,  then you see it.  A few people would and most won't.

Most of us will think, can this be atrial flutter? This is what my other good friends in the ECG Club thought. I checked more than 72 hrs of tele-recordings and could not find the flutter waves. (BTW pt had chronic AF)

What do you think?



ECG Basics: Sinus Rhythm With A Premature Beat

Thu, 03/19/2015 - 16:11 -- Dawn

This strip offers something interesting for both your basic-level students and for your more advanced students.  First, it is a good example of sinus rhythm with a premature beat.  The PR interval was measured by the machine at .21 sec (218 ms).    The premature beat is supraventricular - that is, it is not a PVC.  Because of the slightly long PRI in this strip, it's P wave COULD be buried in the preceding T wave.  That would make this a premature atrial contraction (PAC).  

For discussion with your more advanced students, the P wave could, instead, be retrograde, and occurring during the QRS or slightly after it.  That would make the premature beat junctional, or an atrial echo beat. The origin of the premature beat is mostly academic - there is likely no clinical need to determine the origin.  

In looking for clues as to the origin of the premature beat, we would scrutinize the premature beats for "hidden" P waves.  Upright and before the premature beat would indicate a PAC.  Negative P waves before, during, or after the premature QRS would indicate PJCs.  In this strip, the T waves just before the premature beats are slightly deeper than the other T waves.  This could indicate atrial "echo", or reciprocal beats, which requires the presence of dual junctional pathways, in which the impulse turns around, reenters the atria, and causes a new beat.  It can be helpful to look at multiple leads (the more the better) in your search for P waves.  For a look at this patient's 12-lead ECG, go to this link.  

The P wave of a premature beat often penetrates the SA node and "resets" it, causing the next normal beat to occur after a "normal" R-to-R interval from the premature beat. This fact can help us find "hidden" P waves, as well.

Another interesting feature of this strip for your students who are interpreting 12-Lead ECGs, is that this ECG shows the criteria for left ventricular hypertrophy.  See the link above for the 12-lead and discussion.

 

 

 

 

 

 

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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