okay in our video series of ECG interpretation Made Easy in this video we are going to talk about a ventricular Rhythm called as ventricular tachycardia remember ventricular rhythms include premature ventricular complexes ventricular tachycardia ventricular fibrillation in this video we are going to talk about ventricular tachycardia in my previous video I have talked about premature ventricular complex in detail now normally SA node produces electrical currents and those electrical currents cause depolarization of the Atria these electrical currents travel through internodal Pathways to the AV node AV node sends these signals through the bundle branches to purkanji fiber and purkinje fibers cause contraction of the ventricles the electrical activity of the heart that is called as a sinus rhythm run by SA node now what if the SA node fails to produce electrical currents if essay node fails to produce electrical current AV node takes charge of the hard electrical Rhythm AV node takes control AV nodes produces electrical currents and runs the rhythms of the heart in the absence of SN word what if AV node also fails to produce electric algorithm in such case per kanji fiber takes control of the heart and produces electrical rhythms that cause contraction of the heart muscles this is such a beautiful system if one thing fails second thing takes over if second thing fails the third thing takes over and what if the purkanji fibers fail to produce the electrical currents in such case ventricles start producing electrical currents and those ventricular muscles cause contraction of the heart but these contractions by ventricular muscles are not normal these contractions these electrical signals from the heart muscles are not normal failure of the Atria and AV Junction to initiate the electrical Rhythm of the heart when the SA node fails when the AV node fails when even the purkinje fiber fails in such case the ventricular muscles take control of the electrical activity of the heart that is called as a ventricular Rhythm a rhythm generated by the ventricular muscle that is not a sinus rhythm now coming to the morphology of ventricular rhythms ventricular rhythms produce y bizarre looking waves they produce wide waves because the speed of SA node to depolarize is rapid the speed of ventricular muscles to depolarize is slow therefore there is a huge interval during which the depolarization takes place and the wave that appears on the ECG is wide the T waves are opposite in the direction of R wave now if if this is the r wave of the QRS the T wave will be in the opposite direction that is the classical feature of a ventricular Rhythm p waves possibly might not be visible p waves might be present but since these waves are so wide that they are actually hiding the p waves the QRS interval is greater than 0.12 seconds since I said that these waves are wide so when you calculate the width of the QRS complexes the QRS complex widths will be more than three boxes and that is a wide QRS so the QRS interval will be greater than 0.12 seconds each small box is equal to 0.04 seconds 0.04 multiplied by 3 is 0.12 seconds so these are greater than three small boxes now how do you measure QRS complexes in such ventricular rhythms there might be more wide QRS complexes in one lead and there might be less wide QRS complexes in the other lead so what you do is when you are interpreting the ECG you always choose the widest QRS that is present in any lead now to understand ventricular tachycardia you need to have some knowledge of premature ventricular complex basically what happens in premature ventricular complex is that SA node is normally causing the contraction of the Atria and ventricles there are normal QRS complexes normal sinus beats going on in ECG and all of a sudden and a topic Focus present in The ventricle starts producing current and that current interrupts the normal sinus activity by the SC node the SC node is causing pacing the heart and causing the normal sinus node beads but in between those sinus node beads you will see in a normal wave due to this ectopic Focus that a topic Focus interrupts the normal activity of the SA node that is called as a premature ventricular complex so this is a picture showing a premature ventricular complex these are the normal sinus bits that are going on and in between those sinus beads there is a huge bizarre wide way believe that huge bizarre wide wave is a premature ventricular complex that is interrupting the normal sinus beating of the heart that is called as a premature ventricular complex also called as PVC now when you understand premature ventricular complex it's very easy for you to understand ventricular tachycardia what happens in ventricular tachycardia is three or more premature ventricular contractions occur in a row there is called as a ventricular tachycardia now ventricular tachycardia can be sustained where these premature ventricular contraction last for greater than 30 seconds now this is an ECG showing a normal sinus beat another normal sinus bead and all of a sudden a premature ventricular complex appears and then the premature ventricular complex result in ventricular tachycardia more than ohm3 premature ventricular contractions occur in a row and that is called as a ventricular tachycardia and that is called as a sustained VT when these premature ventricular contractions occur for greater than 30 seconds on an ECG they are called as non-sustained when these premature ventricular contractions last for less than 30 seconds that is called as a non-sustained ventricular tachycardia now in this ccg if you can see this is a P Q R S T wave a normal sinus bead another normal sinus bead and now the premature ventricular contractions start to appear another premature ventricular contraction another PVC another PVC but then this a sequence of PVC ends over here and then sinus B start to appear another sinus beat starts to appear and after that then again there is a PVC another PVC now the PVCs are there but the PVCs are not lasting for more than 30 seconds that is called as a non-sustained perpendicular tachycardia in which there is a ventricular tachycardia for less than 30 seconds and it is interrupted by the normal sinus beads that is a non-sustained ventricular tachycardia that lasts for less than 30 seconds now in a patient with ventricular tachycardia ventricular tachycardia can occur with or without pulses now this is an important point to differentiate it from ventricular fibrillation in ventricular fibrillation whenever the patient gets ventricular fibrillations patients get pulseless patients gets unconscious well in ventricular tachycardia patient can be conscious patient can have pulses even in the presence of ventricular tachycardia anyone in the presence of ventricular tachycardia patients can sometimes have no pulse that is called as a pulseless ventricular tachycardia a ventricular tachycardia where there is no pulse where the ventricles are Contracting such haphazardly that they are not causing contractions of the ventricles properly and but blood is not pumping out from the heart that is called as a pulseless VT where the the ventricles are literally seizing with currents like this the ventricles are having a seizure and they are not actually Contracting therefore there is no pulse that is called as a pulseless VT pulseless VT is an emergency it needs shock you need to defib the patient in pulse full VT in which there is pulse patient can be conscious patient can have pulse and there is still ventricular tachycardia going on and you can treat this type of ventricular tachycardia with medications there is Progressive loss of cardiac output now if you if a patient develops ventricular tachycardia patient can have pulses initially but later on that patient can convert into ventricular fibrillation or that patient can develop pulseless ventricular tachycardia it can very quickly deteriorate to ventricular fibrillation and even a systole where there is flat line now what are the causes of ventricular tachycardia ventricular tachycardia can occur due to re-entry circuit increase automaticity after depolarization in re-entry circuit what happens is that these ectopic prokai are producing electrical currents and those electrical currents travel within the ventricles and they re-enter the ectopic focal and they re-stimulate the ectopics okay to produce more currents a positive feedback loop is formed that is called as a re-entry circuit increased automaticity your heart muscles when it gets damaged after a myocardial infarction heart muscle when it gets damaged due to Chronic congestive failure heart muscles when it gets damaged when it gets abnormal after pathological hypertrophies it can develop increased automaticity where there is increased production of electrical currents and those electrical currents fight with the SA node and they cause abnormal rhythms of the heart and make the a ventricle Seas like this after depolarization normally when the ventricles depolarize there is a wave and then they repolarize and in during the repolarization period there is a period that is called as a refractory period in that refractory period those ventricles can not depolarize again that that that time space that break is important for the electrolytes to re-enage themselves inside and outside the cells but what happens in after depolarization is that the ventricles just got depolarized and they were about to repolarize again but before getting properly repolarized they again get depolarized so that is actually a quick excitation even before a pro a one depolarization has ended another depolarization took place that is called as an after depolarization and that results in arrhythmias in ventricles that causes ventricular rhythms ventricular tachycardias now ventricular tachycardias on ECG can appear like this they can also appear on ECG like this they can have a morphology like this their morphology can also appear like this so these are all different types of ventricular tachycardias that can appear on ECG now coming to the characteristics of ventricular tachycardia in the ventricular tachycardia the heart rate is greater than 100 greater than 100 is a tachycardia 100 to 150 beats per minute is actually called as a slow ventricular tachycardia because normally the ventricular tachycardias are so rapid that they are found around 150 to 300 bits per minute the heart is seizing the heart is at a very fast pace and it is not producing cardiac output sometimes that is called as a pulseless sweetie the regularity the regularity is regular the previous p waves are absent because the ventricles are now in charge of the heart and they are actually causing the heart to cease that therefore you won't see any p waves because these wide QRS complexes are going on in so much speed that they might be one of securing the p waves the P to qrs ratio is not applicable because we do not have the p waves we only have the QRS complexes the wide QRS complexes the PR interval we cannot calculate any PR interval because we do not have the p waves the QRS complexes are wide they are greater than three small boxes they are greater than 0.12 seconds so these are all the characteristics of ventricular tachycardia now let's solve some ECGs this is an ECG showing ventricular tachycardia now remember this is a monomorphic ventricular tachycardia this thing is an important thing to remember there are actually multiple Foci in the heart that are producing these electrical currents in the ventricles but when one focus is dominant over the other Foci of the ventricles when one focus of electrical rhythm is dominant over the others it will produce a ventricular tachycardia that looks the same all waves are similar to each other it means that there is one Focus present in the ventricles that is dominant over the other Foci there are many other Foci that are producing electrical currents but one focus is the alpha male in that the one focus is dominant over others therefore it is producing a monomorphic ventricular tachycardia a monomorphic ventricular tachycardia actually indicates that the one focus is dominant over the other ones now in the next video when we'll talk about polymorphic ventricular tachycardia there will be multiple Foci that will be producing electrical currents and the ECG Rhythm will show a mixture of all of those rhythms that is called as a polymorphic ventricular tachycardia now heart rate if you calculate the atrial heart rate we cannot calculate the atrial heart rate we are unable to obtain the atrial heart rate because there are no p waves if you look at the ventricular rate in ventricular rate one thing that you can do is that you can take the lower end the sharp point and you calculate the number of large boxes in between the good thing would be that you can you calculated by six second methods now if we calculate it by six second method in six I have talked about six second method a heart rate calculation in detail in my video on Rhythm determination I have actually talked about regularity previous PR interval QRS complex in detail in that video the link of that video is given in the description now in six second method basically what we do is that we calculate the we count 30 large boxes we can count 30 large boxes since we have a short strip over here we will count 15 large boxes and in those 15 large boxes we will count the number of QRS complexes that are present then since we have taken 15 large boxes we will multiply the number of QRS complexes by two so it shows the number of QRS complexes in 30 large boxes now the number of QRS complexes present in 30 large boxes multiplied by 10 is equal to heart rate that is the six second method if you want to go into details check out my video on Rhythm determination now one two three four five six seven eight nine ten eleven twelve thirteen fourteen fifteen fifteen large boxes the number of QRS complexes present in the 15 large box is equal to one two three four five six seven eight nine ten ten multiplied by two because we need QRS complexes in 30 large boxes 10 multiplied by two is twenty now answer twenty twenty QRS complexes are present in 30 large boxes the answer is multiplied by 10 is equal to heart rate 20 multiplied by 10 is 200 bits per minute 200 beats per minute is the ventricular rate in this Rhythm by 6 second method regularity is regular p waves are absent P are interval we cannot calculate we do not have the p waves now let's look at the QRS complexes the QRS complexes are actually having one two three three and a half so there there are basically more than three small boxes present that is a wide QRS complex three or more than three small boxes in a QRS complex is a wide QRS complex each small box is equal to 0.04 so almost three multiplied by zero point zero four is zero point one two to zero point one six second is the QRS width interpretation this is a sustained ventricular tachycardia sustained because we do not see any sinus rhythm in it it is a sustained UT now what you should do is pause the video take a piece of paper a pencil and solve the ccg solve the ccg is yourself till the time you don't solve these yourselves you won't remember anything this is another picture of ventricular tachycardia now going to the answer of this ECG let us calculate the heart rate let us apply the six second method will calculate 15 boxes since we have a short strip we do not have 30 boxes and then we will multiply the answer by 2 so that we get the QRS complexes in 30 large boxes we have 1 2 3 4 5 6 7 8 9 10 11 12 13 14. 15 15 large boxes in the 15 large boxes we have one two three four five six six QRS complexes in 15 12 QRS complexes in 30. 12 multiplied by 10 is 1 20 bits per minute so we have ventricular rate of 120 beat per minute in the ccg it will rate we are unable to obtain since we have no p waves the rate is regular the p waves are absent PR interval is not there let us look at the QRS complexes so we have one two three four almost four small boxes so even we have more than three small boxes that is a wide QRS complex coming to the interpretation this is a sustained slow ventricular tachycardia as I said from 100 to 150 that is a slow ability although it's a rapid rate but still according to VT it's a slow VT pause the video solve this ECG yourself this is the ECG of ventricular tachycardia now coming to the answers let's calculate the rate it will rate unable to obtain let's calculate 15 boxes one two three four five six seven eight nine ten eleven twelve thirteen fourteen fifteen in 15 large boxes we have one two three four five six seven seven QRS complexes in 15 large boxes 14 QRS complexes in 30 large boxes so 14 multiply by 10 is equal to 140 so the ventricular rate is 140 by 6 second method regularity is regular the p waves are absent PR interval cannot be determined now let us look at the QRS complexes the QRS complexes are huge over here will one two three four five five small boxes five small boxes five multiplied by 0.04 is 0.20 seconds interpretation is sustained ventricular tachycardia which is slow because the heart rate is 140. in this ECG you can see this is the sinus rhythm going on normal P wave QRS narrow QRS complex is less than three small boxes QRS complexes either normal QRS complexes it means that the say node is running the heart rate there are p waves and QRS complexes are present but then there is a premature ventricular complex a PVC is present and that PVC puts the heart into a ventricular tachycardia and that is a sustained VT because after this we do not see any normal sinus beat now let's calculate the rate in this I have already calculated the rate it's 120 beats per minute the regularity is irregular since look at the RR interval over here and let us look at the RR interval over here so this PVC is actually causing irregularity in one Rhythm we have an irregular rate p waves are present till here after that p waves are absent so p waves are present plus Merit to the QRS complex until the patient developed ventricular tachycardia let's look at the PR interval PR interval we have one two three four four small boxes four small boxes multiply four multiplied by 0.04 is 0.16 seconds then they are absent because patient developed VT so we have to comment on both sides the normal sinus bits as well as the ventricular tachycardia side let's look at the QRS complexes we'll take the widest QRS complex the wide SQ is pure s complexes two small boxes white that is zero point zero eight seconds that's normal less than three small boxes that's the sinus beat until the patient developed premature ventricular contraction and VT the premature ventricular contraction is having one two three small boxes and three or more than three small boxes wired QRS is a wide QRS interpretation of this ECG is that the patient had sinus rhythm then that patient developed PVC after the PVC patient went into a sustained ventricular tachycardia this is so easy now coming to the management of ventricular tachycardia management of ventricular tachycardia is very important as you commonly see ventricular tachycardia in the wards in many patients no as I said patient with ventricular tachycardia can be stable patient can have pulses with ventricular tachycardia patient can be conscious with ventricular tachycardia while in ventricular fibrillation patient very quickly get unconscious patient very quickly loses the pulses while in ventricular tachycardia patient can be stable but remember patients a stable patient with ventricular tachycardia will very quickly decompensate if you don't treat it if you don't manage it so a patient with ventricular tachycardia can develop pulseless VT anyone go into ventricular fibrillation which is lethal now if the patient is stable you can do pharmacologic intervention you can treat the patient with medicine but if the patient is unstable if the patient is having pulseless Beauty where there are no pulses or if the patient is losing pulses patient is losing blood pressure and the patient is getting unstable the next thing you have to do is you have to shock the patient if the patient is unstable shock the patient you do DC cardioversion you shock the patient and you revert the Rhythm straight away now if the patient is unstable and patient's ECG shows ventricular tachycardia the next thing you have to do is that you have to start CPR straight away till the time the defibrillator is available you have to follow the ACLS protocol I'll zoom in on this the first thing that you have to do till the time the nurse brings the defibrillator or the doctor brings the Deep liability you have to start CPR you start doing CPR you have you initiate the ACLS protocols I have talked about Cardiac Arrest protocols in detail in my video on Cardiac Arrest management the link of that video is in the description you start CPR you give oxygen you attach monitor you bring the defibrillator and if the patient is having ventricular tachycardia a pulseless ventricular tachycardia ventricular tachycardia where there is no pulse you straight away shock the patient you give shock then after that you recontinue this you re-start the CPR you restart the CPR and then you reassess the Rhythm that whether the rhythm again is shockable or not whether the patient is still having ventricular tachycardia or not whether the patient has developed ventricular fibrillation if there is ventricular tachycardia if there is ventricular fibrillation that is a shockable rhythm if the patient develops a systole a flat line or pulseless electrical activity in that situation you cannot give shocks in ventricular fibrillation or pulseless wheat you can give shock that that is a shockable rhythm so we FIB we attack you shock now if it is a shockable rhythm you again give shock to the patient you again defibrillate the patient and then you continue CPR and with that you give epinephrine 1 mg every three to five minutes and then again you check the Rhythm that whether the rhythm is shockable or not if there is way we tap you again give the shock and after this shock you give a miterrone or lidocaine I'll talk about the metro and Lidocaine in a while if the rhythm is not shockable you move on to the other side of ACLS side another side of the ACLS where the Rhythm Is non-shockable In The non-shockable rhythms the only thing that you can do is that you can give CPR and you can give epinephrine there is nothing else that you can do in the non-shockable side in the shockable side you shock you check you continue CPR you give epinephrine you check the rhythms you give continuous CPR you check the Rhythm if it is still shockable you again shock the patient and then you give a midrone or lidocaine so this is the ACLS protocol I'll post this chart on my Facebook page so that you can easily download it now coming to the doses I'll I'll read these things out because these things are written very small epinephrine is one mg every three to five minutes amidoron is first dose is 300 mg Bola second dose is 150 mg or if you are not giving midor on you can give lidocaine IV first dose 1 to 1.5 mg per kg second dose 0.5 to 0.75 mg per kg you look for the reversible causes in the causes of patient developing ventricular tachycardia you look for hypovolemia hypoxia you check for acidoses hydrogen ion you send ABG is hypovolemia hypokalemia hyperkalemia hypothermia tension pneumothorax cardiac tamponade toxins thrombosis thrombosis coronary arteries thrombosis pulmonary thrombosis so these are all the h4h and four T's that you have to check while giving the CPR and if the patient is stable if the patient is conscious and if the patient is having pulses in such situation you can go for pharmacological cardioversion you don't need to give shocks to the patient in such case you give IV amidorone 150 mg IV over 10 minutes followed by 1 mg per minute for the next 6 hours or you can give IV lidocaine 1 to 1.5 mg per kg typically 75 to 100 mg at the rate of 25 to 50 mg per minute or you can give IV proconamide if amidorone and Lidocaine are not available 20 to 50 mg per minute until arrhythmia terminates the maximum dose is 15 to 17 mg per kg now if what if the patient gets the pharmacological treatment but still the Rhythm Is Not reverted in such patients you go for a defibrillation you tell the patient that we are trying to abort the Rhythm that abnormal Rhythm can be lethal but with the drugs we have failed to abort the Rhythm now we need to cardiover the patient in a conscious patient remember remember always say dear to the patient first then give shocks it's criminal to give shocks to a conscious person you first sedate the patient you either give midazolam you studied the patient for some time and then you cut your word the patient in uh in a stable patient with VT that is unresponsive to the pharmacologic interventions other than that if the patient is developing non-sustained VTS frequently in such patients you put implantable cardio water defibrillator what implantable cardiovert or defibrillator does is that it detects whenever the heart develops abnormal ventricular contractions or abnormal ventricular rhythms and it bombards these abnormal ventricular rhythms with the signals and currents and stops them suppresses them it is always present is it is a device that is placed present with the patient's heart all the time and it detects the abnormal Rhythm it bombards them abnormal rhythms and it controls the abnormal Rhythm so that the patient does not develop VT sustained VT General measures include correction of electrolytes remember in all arrhythmias in all arrhythmias always always correct electrolytes the basic the very basic thing is to correct the electrolytes because many times these electrolyte abnormalities are causing arrhythmias and you are looking for the big causes while you are missing out the very basic things hypoxia should be corrected acidosis should be corrected hypomagnesemia hypokalemia should be corrected beta blocker are effective in prevention of a ventricular tachycardia if the patient is developing non-sustainability beta blockers can be given to control the ventricular tachycardias if you liked my video please click on the Subscribe button and check out my other videos on ventricular fibrillation and polymorphic ventricular tachycardia premature ventricular complexes the leak of those videos are given in the description below in this video we talked about what is ventricular Rhythm what is the morphology of ventricular rhythm what are premature ventricular complexes three or more previous your ventricular complexes in a row is called as ventricular tachycardia how can ventricular tachycardia present the causes the different morphologies the characteristics of ventricular tachycardia and the management of ventricular tachycardia the CPR protocol the ACLS protocol in an unstable patient with VT the general management measures 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 video is given in the description below thank you very much and if you want to support this channel you can support us on buy me a coffee the link of that is also given in the description thank you very much