Clinical Cases

12/06/2024

🛑ECG TIPS : Complex Tachycardia #

The differential diagnosis of wid complex Tachycardia can be

1/ ventricular

2/supraVentricular

🔺It’s important to differentiate wide complex SVT from ventricular tachycardia (VT), as the management strategies differ.

🔺It's important to know the mechanism of each type. then we will explore the ECG feature and how to differentiate between them.

🔺To day wll talk about Wide complex SVT

◾Wide complex supraventricular tachycardia (SVT) is a type of Arythmia originating above the ventricles but presenting with a wide QRS complex on an electrocardiogram (ECG). Normally, SVT has a narrow QRS complex, but in some cases, the QRS complex becomes wide due to abnormal conduction through the ventricles. This can happen for a few reasons:

1. **Bundle Branch Block (BBB)**: An existing conduction delay in one of the bundle branches can cause the QRS complex to widen.
2. **Pre-excitation Syndromes**: Conditions like Wolff-Parkinson-White (WPW) syndrome, where an accessory pathway bypasses the normal AV conduction system, can cause a wide QRS complex.
3. **Aberrant Conduction**: During a rapid heart rate, the normal conduction pathway can temporarily function abnormally, leading to a wide QRS complex.

09/06/2024

🛑 ECG Tips : Approach to tachycardia

◼️First step look at QRS complex is it narow or wide?( Wide if more than 3small squares ).

◼️IF QRS is narrow then the source of Arythmia is supraVentricular (above the bundle of his)

◼️Next step is to ask yourself Is the rythm is regular?

◼️IF NO(irregular rythm)the the differential diagnosis will be
1/Atrial fibrillation

2/Atrial flutter with variable block

3/Multfocal Atrial
tachycardia

4/Paroxysmal atrial tachycardia

5/Focal Atrial tachycardia with variable AV block

◼️To differentiate between those types look at the P wave

◼️IS P wave present??

🔹If no this is Atrial fibrillation

🔹IF yes ,and it has saw_tooth shape (multiple p waves)this is Atrial flutter with variable blocks

🔹IF the Pwave is abnormal in shape(might be inverted and only one P wave) then this is focal Atrial tachycardia with variable block.

🔹IF P wave has abnormal shapes and its more than one shape this is Multfocal Atrial tachycardia.

◾ IF the rythm is regular the differential will be

1/Sinus bradycardia

2/Atrial tachycardia

3/Atrial flutter

4/SVT (AVNRT)

5/Atrial tachycardia

🔷To differentiate between them look at the P wave :

▪️IF P Wave has normal shape this is sinus tachycardia

▪️IF the P wave
is abnormal then this is Atrial tachycardia (usually inverted P wave)

▪️IF there is more than one Pwave ,and has Saw_tooth shape this is Atrial flutter

▪️IF you just see T Wave this is SVT (AVNRT).

Next post will be about broad Complex Tachycardia.

06/06/2024

🛑Vertigo

🔺Vertigo is the sensation that the environment is spinning around ,relative to oneself (objective vertigo ) or vice versa (subjective vertigo).

🔺Most of the causes are benign, but we have to exclude the serious causes.

🔺differential of Vertigo include the following:

1/ Cardiac when the patient develop vertigo on standing which resolve by sitting down or Lying on the bed.

2/Neurological ,the patient will complain of other neurological symptoms (weakness, sensory symptoms, cranial nerve lesions, cerebellar symptoms).

3/Vestibular and this include :

◼️Benign paroxysmal positional vertigo. usually sudden onset and less than 30 seconds precipitated by specific head movements with absence of associated neurological or otological symptoms.

◼️Meniere's disease،episodic, sudden onset of vertigo, hearing loss and roaring tinnitus and a sensation of pressure or discomfort in the affected ear. Vertigo lasts minutes to hours and may be associated with nausea and vomiting.

◼️Vestibular migraine affects approximately 20% of patients with migraine. Symptoms include spontaneous and positional vertigo, head motion vertigo/dizziness and ataxia, all of variable duration, ranging from seconds to days, and independent of migraine associated headache.Photophobia, phonophobia, or aura may be diagnostic symptoms.

◼️Inner ear infections and labyrinthitis, which usually follow viral upper respiratory tract infections or bacterial otitis media

◼️Vestibular neuritis , recurrent attacks for seconds, usually follow a respiratory tract infections.

06/06/2024

04/06/2024

◻️How to approach patients present with dizziness :

◻️When patient complain of dizziness usually mean one of the following :

1/Vertigo
2/Syncope
3/Per-syncope
4/Imbalance
5/lightheadedness.

To approach patient presented with dizziness :

First step is to know, what the patient mean by dizzines by asking direct questions, then asking about timing and triggering factors.

◻️Do you feel the room spinning around you ?
If yes this vertigo, which has many causes :

1-Vestibular
2-Neurological
3-Cardiac

◻️If the patient lose consciousness and fall dawn this is Syncobal Attack and the cause is usually cardiac in orign

1-Arythmia
2-Heart block
3-Valvular heart disease.

◻️If the patient state that he cannot walk steadily this is imbalance and the cause is neurological.

◻️If the patient discribed his condition as if he is going to lose consciousness,but he didn't this is lightheadedness or per-syncope which might be caused by:

1-Cardiac cause
2-Anaemia
3-Hypotension

02/06/2024

ECG TIPS: of bradycardia #

When you see bradycardia on ECG Frist step in approach is to check the rythm

IF the rythm is regular, the differential will be :

1/3 degree heart block

2/Sinus bradycardia

Next step to differentiate between sinus bradycardia and 3 degree heart block is to check the Pwave:

IF every QRS proceeded by P Wave this is Sinus bradycardia .

but if P wave has no relation to WRS then it's 3degree heart block .

IF the rythm is irregular the Cause will be Second degree heart block.

If there's progressive prolongation of PR interval Untill QRS missed this is Mobitz1

But when the PR interval is same but every 2 or 3 normal QRS ,One QRS is missed this is mobitz2 second degree heart block.

01/06/2024

*ECG TIPS*: *interpretation of irregular rythm?*

Whenever you see an irregular rythm in ECG the differential will be one of the following:

1/sinus arythmia

2/Atrial fibrillation

3/Atrial ectopics

4/Ventricular ectopics

5/ second degree heart block

the first step in irregular rythm approach is to look for p wave, qrs complex, and pr interval.

IF P wave is present and has normal shape with normal QRS this most likely sinus arythmia

IF P wave is absent with normal QRS complex the diagnosis will be atrial fibrillation

IF P wave is present but sometimes has different shape with normal PR interval and QRS complex ,the diagnosis is atrial ectopics

IF P wave is present and has notmal shape and normal. PR interval, but sometimes there is QRS which have different shape the diagnosis is ventricular ectopics

IF P wave is normal and QRS is normal but there's progressive prolongation of PR interval untill one beat is missed (no QRS) the diagnosis will be mobitz1 second degree heart block.

IF pwave ,QRS and PR interval are normal and there are 2 or 3 normal beats and one beat missed(no QRS) before 2 or 3 normal beats appears again this is mobitz2 second degree heart block.

31/05/2024

ECG Tips : we Approach ECG in three Steps

Step 1: Essential

1/you have to confirm the name,date and time.

2/ Confirm that the speed is the standard one 25mm/S and the Caliper is 1mv/10mm, because this will affect the rate Calculation and assessment of ST segment and voltage of the QRS.

3/Confirm the leads are placed correctly by checking AVR and V1 both must be negative (S wave is deeper than R wave).

Step 2: general

1/ Check The Axis ( look at Lead 1and lead 3 if both of them have tall are waves then it's normal but if lead 1 have tall R wave while lead 3 have deep S wave it's left Axis deviation (أصحاب الشمال متنافرين), When lead 1 have deep S wave and there's tall R wave in lead 3 it's Right Axis deviation ( أصحاب اليمين متقابلين).

2/ Check if The rythm is regular by measuring the distance between R waves if it's equal the rythm is regular.

3/ Count the heart Rate divide 300 by the number of squares between 2 R waves if the rythm is regular.

Step 3: details

Check each part of ECG in each lead if it's normal Starting from :
Pwave
PR interval
QRS
ST segment
Twave
QT interval