okay in our video series of ECG interpretation Made Easy in this video we are going to start ventricular rhythms ventricular rhythms include premature ventricular complexes or ventricular tachycardia ventricular fibrillation now in this video we are going to mainly focus on premature ventricular complexes in the subsequent videos we'll be talking about ventricular tachycardia ventricular fibrillations now how does this ventricular Rhythm arise what does ventricular Rhythm means now in our heart essay node is the basic pacemaker it produces electrical currents and those electrical currents cause contraction of the Atria these electrical currents spread out to the AV nodes through the internodal pathways and AV node sends these signals to the bundle branches to the perkanji fibers and then it causes contraction of the ventricles that's how the heart beats SA node is the basic pacemaker now what if this SC node fails to produce the electrical current what if the SA node fails then even node takes the charge of the heart AV nodes takes the responsibility of producing the electrical currents and EV nodes runs the electrical rhythms of the heart what if even wood also fails to produce electrical rhythms in such case per kanji fiber takes the charge of electrical activity and purkinje fiber produce electrical currents there to run the rhythms of the heart but what if the person G fiber also fails if the purkinje fiber fails after that ventricles start producing electrical currents and the ventricular tissue produces electrical current that causes contraction of The ventricle so that the blood keeps running throughout the body that's such a beautiful mechanism of the body that we have almost four Fail-Safe mechanisms but the last one is not a normal phenomena when the ventricles take charge of the electrical activity the things go wrong in the heart failure of Atria and AV Junction to initiate a bit results in electrical rhythms being generated from the ventricles those rhythms are called as ventricular rhythms they include ventricular tachycardia ventricular fibrillation polymorphic ventricular tachycardia premature ventricular complexes now sometime it happens that the ventricular tissue gets a myocardial infarction the ventricular tissue gets ischemia it gets damaged and they damaged heart tissue that damage ventricular tissue produces these electrical currents and it fights with the SA node electrical activity it fights with the Lesser node electrical activity and what happens in the fight between sa nodes and the ventricular rhythms Hearts suffer the body suffers patient can develop cardiac arrest and this these situations are very lethal for the patient now what is the morphology of ventricular Rhythm morphology of ventricular Rhythm Is Wild bizarre looking waves remember when XA nodes depolarizes it gives you narrow waves the sharp QRS complexes the sharp waves but when the ventricles take charge of the electrical activity of the heart ventricles depolarize slowly so what you will see is that you will see wide QRS complexes so wide bizarre looking waves the T wave is opposite in direction to the r wave now if this is a wide QRS complex greater than three small boxes on ECG and the T wave will be opposite the T wave will be inverted that is a classical feature of a ventricular contraction ventricular pacemaker activity the p waves will possibly be not visible the p waves might be present but since the ventricles are Contracting at a fast pace and the ventricular rhythms are wide they will hide the p waves the QRS interval will be greater than 0.12 seconds because the QRS complex is wide because these are white bizarre looking waves and it will be greater than three small boxes on ECG that's a wide QRS now this is a picture showing a normal sinus bead and it Compares it with a ventricular bead now if you look at the normal bit this is P wave this is the narrow QRS complex and this is the T wave this one over here is a ventricular bead and this ventricular bead is a wide bizarre wave and look at the T wave the T wave is inverted and there is no P wave this is a T wave of the previous beat but there is no P wave the P wave is possibly hidden by this QRS complex now how do you measure QRS complex in these wide bizarre ventricular rhythms maybe the one lead might be showing more wide QRS complex and the other lead might be showing less wide QRS complex in the interpretation you always choose the widest QRS complex and you label the widest QRS complex size now coming to premature ventricular complexes PVCs now what happens in premature ventricular complexes is that the SA node is normally firing and producing electrical currents and it is causing the heart to beat but in between that normal sinus rhythm a ventricular ectopic Focus produces electrical currents and it disturbs the electrical activity of the heart it disturbs the electrical activity of SA node so a normal sinus rhythm is going on and in between an ectopic Focus From the ventricles produces electrical currents and it disturbs the normal sinus rhythm that is called as a premature ventricular complex so premature ventricular complex is an ectopic beat that interrupts the normal Rhythm of the heart now in this ECG these are the normal sinus beads that are going on this is another normal sinus bit and in between look over here this is the premature ventricular complex this is the disturbance in the normal Rhythm the normal sinus rhythm the premature ventricular complex interrupts the normal rhythm now this premature ventricular complexes are caused by irritable focus in the ventricular wall that produces the electrical currents or in the conduction system or due to re-entry phenomena of the electrical currents where the current re-enters that ectopic focus it re-initiates another beat and that currents then re-enters at that ectopic focus and re-initiates a bit now basically these things are caused whenever myocardial tissue is damaged Whenever there is myocardial ischemia Whenever there is previous history of Mi those dead tissue those damaged myocardial cells have the potential to produce these abnormal electrical rhythms and these electrical Rhythm disturb the normal rhythms of the heart now what is the significance of premature ventricular complex now remember a premature ventricular complex might be present on the ECG and patient may be totally asymptomatic patient may be totally fine the only finding would be that the patient will be having an irregular rhythm because these premature ventricular complexes are disturbing the normal Rhythm the normal beats of the heart but the importance is that even if the patient is stable you should go for workup that what is the problem what is the pathology in the heart what is the pathology in the ventricles because it can precipitate into a ventricular tachycardia ventricular fibrillation which is a lethal and remember it can also decrease the cardiac output now if after every normal sinus beat there is a premature ventricular complex and that premature ventricular complex does not cause a proper contraction of the heart the blood will not be pumped out to the peripheral tissues so after every sign has beat if there is a premature ventricular complex and that premature ventricular complex is not producing any cardiac output so if the rate is 80 bits per minute the actual heart rate is 40 bits per minute because the 40 bits are perfusing the body with blood and those 40 bits of premature ventricular complexes are useless because they are not pushing the blood out from the heart so it can decrease the cardiac output now this is a picture showing the premature ventricular complex void bizarre wave with an inverted T wave now in this ECG if you look this is a normal sinus bead this is a P wave a narrow QRS complex and it is followed by a wide QRS complex a wide bizarre QRS complex and that white bizarre QRS is having an inverted T wave so this is a premature ventricular contraction this is another normal sinus bit which is followed by a premature ventricular contraction and it goes on so this is where a patient is having a normal beat and a premature ventricular complex a normal beat a premature ventricular complex that is called as a bijeminal PVC this is another ECG showing by geminal PVC we can easily spot if you look at the Rhythm strip over here you can easily see this is a normal sinus bit with sharp narrow QRS complex the narrow QRS complex is the one which has the less than three small boxes in it and look over here this is a huge QRS complex a wide bizarre QRS complex for with an inverted T wave a wide QRS complex with an inverted T wave that is a premature ventricular contraction this is the premature ventricular contraction so every normal sinus beat is followed by a premature ventricular complex that is called as a by geminal PVC now if after every two sinus beads there is a third PVC that is called as a trigeminal PVC after every two sinus beads there is a third PVC that is called as a trigeminal PVC if after every three sinus beads there is a PVC a huge QRS complex that is called as a quadri geminal PVC now if you look at this ECG in this ECG you can look at these wide QRS complexes with inverted T waves these are bizarre looking QRS complexes wide QRS complexes these are premature ventricular contractions and look how they are disturbing the normal Rhythm they disturb the normal sinus B look at the RR interval over here look at the RR interval over here so this they disturb the normal sinus rhythm and if it is followed by three sinus speeds there is a quad Regional PVC PVC couplet if these QRS complexes are present together in a form of couple that is called as a PVC couplet now these two QRS complexes are PVCs these two QRS complexes are PVCs now let's solve some ECGs now I have talked about heart rate calculation regularity p waves PR interval QRS complexes in detail in my video on Rhythm determination the link of that video is given in the description below now as we discussed in that video that if the rhythm is irregular in scg what you do is that you calculate the heart rate in an irregular ECG by 6 second method what you do in six second method is that you can you count 30 large boxes you count the 30 large boxes and then within those 30 large boxes you count the number of QRS complexes present if the QRS complexes are let's say 8 and then you multiply the 8 with the number 10 so the heart rate is 80 beats per minute now in this ECG since the ECG strip is short what we'll do is that we will count 15 large boxes 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 and then we'll count the QRS complexes in it we have one two three four QRS complexes so now we will multiply 4 by 2 since we have to calculate 30 large boxes but the strip is short so we have calculated 15 so we will multiply the number with two so four multiply by 2 is 8. and then so this means that in the 30 large boxes we have eight QRS complexes now we'll multiply this 8 to 10. so 80 is the heart rate in this ECG so the heart rate in the ccg is 80 bits per minute regularity is irregular the p waves are present the p waves are Merit to the QRS complexes the p waves are normal there is no such P wave which is not followed by the QRS complex so p waves are present and they are Merit to the QRS complexes let us look at the PR interval so the PR interval starts from the start of P wave to the start of R wave so we have one two three four four small boxes each small box is equal to 0.04 seconds so 4 multiplied by 0.04 is 0.16 second and a normal PR interval is less than or equal to 0.20 seconds so this is a normal PR interval or you can simply remember that a normal PR interval is the one in which the PR interval is less than one large box that is a normal PR interval so this is one less than one large box wide now let's look at the QRS complex the QRS complexes are narrow sharp angles T points let us look at the number of small boxes in the QRS complex we have one two two small boxes in the QRS complex and that is equal to 0.08 seconds less than three small boxes is a normal QRS complex but in this ECG we have an abnormal QRS complex and we have to mention that as well so we have a PVC and the size of that PVC is one two three four almost four small boxes that is a wide QRS complex it is more than three small boxes so 4 into 0.04 is 0.16 second so the interpretation of this ECG is sinus rhythm there is a sinus rhythm but it is interrupted with PVC the interpretation of this Rhythm Is Not Just premature ventricular contraction the interpretation is sinus rhythm with the premature ventricular contraction now what you should do is that you should pause the video take a piece of paper and a pencil and solve the ccg you should solve these ECGs yourself if you want to take help you should go on my video on Rhythm determination and you check that how to calculate heart rate regularity I've talked about them in detail now let's calculate the heart rate now this is an irregular ECG an irregular ECG heart rate is calculated by the six second method in which you have to calculate the number of QRS complexes in the duration of 30 large boxes so let's calculate the 30 large boxes I have already pointed out the I have already marked it on ECG this is the 15 large box interval this is the 15 large box interval so this is a 30 large box interval in that 30 large box interval we have one two three four five six six QRS complexes so 6 QRS complex is in 30 large box distance 6 is to be multiplied by 10 6 multiplied by 10 is 60 beats per minute so that's the six second method so the heart rate is 60 beats per minute the regularity is irregular the p waves are present now if you look at this small this is less prominent P wave but p waves are there if you focus on it this is a small P wave this is a small P wave over here it's more prominent over here it's more prominent so these are the p they are followed by the QRS complexes they are married to the QRS complexes now let's look at the PR interval let's count the small boxes in the PR interval one two three four four small boxes so it is 0.16 second let's look at the QRS complex the QRS complexes are narrow sharp angle steep points one large box white so it is 0.04 seconds a normal QRS complex but with this normal QRS complex we also have PVCs the abnormal bizarre wide QRS complexes let's look at the number of small boxes in these PVCs we have one two three and more than almost more than three small boxes so we have 0.12 seconds less than three is a normal QRS complexes three or more than three is the void QRS complex the interpretation of this ECG is sinus rhythm with premature ventricular contraction now let's solve this ECG let's calculate the heart rate by six second method this is the 15th large box interval since the ECG strip is short we will calculate 15 then we'll multiply it by 2 so that we get a 30 large box interval and after that we will count the QRS complexes and multiply it by 10 that is the six second method now let's count the QRS complexes you have one two three four four multiplied by two is eight so eight uh QRS complexes are present in thirty uh large box interval and eight multiplied by ten is 80 beats per minute so we have 80 bits per minute heart rate the regularity is irregular p waves are present these are the p waves they are married to the QRS complex they are followed by the QRS complexes let's look at the PR interval we have one two three four almost four small boxes wide so 0.16 second let us look at the QR a QRS interval the QRS interval over here looks wide then the sinus beads are having a wide QRS complexes so we have one two three almost three ah small boxes there is actually a wired QRS complex zero point one two seconds let us look at the PVCs the PVCs one two three so that is 0.12 seconds the interpretation of this ECG is sinus rhythm with premature ventricular contractions now coming to the management of premature ventricular contractions remember as I said that the patient might be asymptomatic and the patient ECG might show premature ventricular contractions most patient even do not require treatment but premature ventricular complexes if they appear on ECG that person must receive an echo that person should get an echocardiography to look at the cardiac defects that are causing these premature ventricular contractions you look you identify the pathology and you treat the underlying disease if the patient is symptomatic if there is very rapid heart rate in such situations what you can use is that you can use beta blockers but you do not use beta blockers in patients who are estimating if the beta blocker spill then you can do catheter ablation whatever that topic focus is producing those ah ectopic electrical currents you ablate that you burn that ectopic Focus before going into the summary if you liked my video please click on the Subscribe button we talked about what is ventricular Rhythm we talked about morphologies of ventricular Rhythm we talked about premature ventricular complexes their origin what are they are caused by their significance by geminal PVCs trigeminal PVCs quarter geminal PVCs PVC couplers and the management of premature ventricular complexes if you liked my video please click on the Subscribe button and check out my other videos on ECG interpretation Made Easy video series the link of that series is given in the description below thank you very much