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aVR and V4R

ECG of the right heart
by

Jacques Loubser

on 10 April 2014

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Transcript of aVR and V4R

http://lifeinthefastlane.com/wp-content/uploads/2011/07/ECG-Anatomy-LITFL.jpg
Goldberger
TCA overdose
VT/aberrant
Patients need to be managed in a monitored area equipped for airway management and resuscitation.

Secure IV access, adminster high flow oxygen and attach monitoring equipment.

Administer IV sodium bicarbonate 100 mEq (1-2 mEq / kg); repeat every few minutes until BP improves and QRS complexes begin to narrow.

Intubate as soon as possible.

Hyperventilate to maintain a pH of 7.50 – 7.55.

Once the airway is secure, place a nasogastric tube and give 50g (1g/kg) of activated charcoal.

Treat seizures with IV benzodiazepines (e.g. diazepam 5-10mg).

Treat hypotension with a crystalloid bolus (10-20 mL/kg). If this is unsuccessful in restoring BP then consider starting vasopressors (e.g. noradrenaline infusion).

If arrhythmias occur, the first step is to give more sodium bicarbonate. Lidocaine (1.5mg/kg) IV is a third-line agent (after bicarbonate and hyperventilation) once pH is > 7.5.

Avoid Ia (procainamide) and Ic (flecainide) antiarrhythmics, beta-blockers and amiodarone as they may worsen hypotension and conduction abnormalities.

Admit the patient to the intensive care unit for ongoing management.
Flecainide
VT

SVT with aberrant conduction due to bundle branch block

SVT with aberrant conduction due to the WPW syndrome
For VT:

Absence of typical RBBB or LBBB morphology

Extreme axis deviation (“northwest axis”) – QRS is positive in aVR and negative in I + aVF.

Very broad complexes (>160ms)

AV dissociation (P and QRS complexes at different rates)

Capture beats — occur when the sinoatrial node transiently ‘captures’ the ventricles, in the midst of AV dissociation, to produce a QRS complex of normal duration.

Fusion beats — occur when a sinus and ventricular beat coincides to produce a hybrid complex.

Positive or negative concordance throughout the chest leads, i.e. leads V1-6 show entirely positive (R) or entirely negative (QS) complexes, with no RS complexes seen.

Brugada’s sign – The distance from the onset of the QRS complex to the nadir of the S-wave is > 100ms

Josephson’s sign – Notching near the nadir of the S-wave

RSR’ complexes with a taller left rabbit ear. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller.
Verecki algorithm
A dominant initial R wave in aVR is indicative of VT.

A dominant terminal R’ wave in aVR (i.e. following a Q/S wave) is more likely SVT with aberrancy — this pattern is most commonly seen in tricyclic poisoning.
RBBB: rsR'
VT: qR'
AVNRT with LBBB
Monomorphic VT
TCA
VT
TCA
antidromic WPW in 5y old
Ventricular paced
LMCA occlusion
Widespread horizontal ST depression, most prominent in leads I, II and V4-6

ST elevation in aVR > 1mm

ST elevation in aVR > V1
Diffuse subendocardial ischaemia (producing reciprocal change in aVR)

Transmural ischaemia / infarction of the basal interventricular septum (e.g. due to a proximal occlusion within the left coronary system)
STE in aVR ≥> 1mm indicates proximal LAD / LMCA occlusion or severe 3VD

STE in aVR >≥ 1mm predicts the need for CABG

STE in aVR >≥ V1 differentiates LMCA from proximal LAD occlusion

Absence of ST elevation in aVR almost entirely excludes a significant LMCA lesion
"When patients with ACS, including non-STE ACS, demonstrate STE in lead aVR, the aggressiveness of early management must be increased. These patients have more complex coronary lesions and will likely benefit from earlier invasive therapy."

Amal Mattu 2009
Anton P.M. Gorgels, MD, PhD; D.J.M. Engelen, MD; Hein J.J. Wellens, MD, PhD
J Am Coll Cardiol. 2001;38(5):1355-1356. doi:10.1016/S0735-1097(01)01564-9
Exp Clin Cardiol. 2010 Summer; 15(2): e36–e44.
PMCID: PMC2898534
Clinical Cardiology: Review
aVR – the forgotten lead
Anil George, MD,1 Pradeep S Arumugham, MD,2 and Vincent M Figueredo, MD2,3
Quiz
lead placement

Looking at
a forgotten corner of the heart
I love ED CME
update by J Loubser
4/4/2014
Case scenario:

50y Female
Day after Valentine's day
Found in her garden

BIBA
Arrives GCS 8/15
BP 90/60
PR 125
Interventricular conduction delay – QRS > 100 ms in lead II
QRS > 100 ms is predictive of seizures
QRS > 160 ms is predictive of ventricular arrhythmias (e.g. VT)

Right axis deviation of the terminal QRS:
Terminal R wave > 3 mm in aVR
R/S ratio > 0.7 in aVR
Same patient but on arrival:

GCS 15/15 complaining of right shoulder pain
worsening TCA
TCA
bad TCA
LMCA
LMCA with interventricular conduction delay
RV infarction
Right ventricular infarction complicates up to 40% of inferior STEMIs.

Isolated RV infarction is extremely uncommon.

Patients with RV infarction are very preload sensitive (due to poor RV contractility) and can develop severe hypotension in response to nitrates or other preload-reducing agents.

Hypotension in right ventricular infarction is treated with fluid loading, and nitrates are contraindicated.
ST elevation in V1 - the only standard ECG lead that looks directly at the right ventricle.

ST elevation in lead III > lead II - because lead III is more “rightward facing” than lead II and hence more sensitive to the injury current produced by the right ventricle.
ST elevation V1 > V2

ST normal V1, depressed V2

ST elevation III > II
Very sick

Combat acidosis

Use fluid

Avoid anti arrhythmics
VT: Rsr'
Inf STEMI = ? RV infarct

Give fluids not GTN!
Acknowledgments:

Tor Ercleve, thanks for images

Life in the Fastlane, for most of the info

Wikipedia creative commons

"When patients with ACS, including non-STE ACS, demonstrate STE in lead aVR, the aggressiveness of early management must be increased. These patients have more complex coronary lesions and will likely benefit from earlier invasive therapy."

Amal Mattu 2009
Anton P.M. Gorgels, MD, PhD; D.J.M. Engelen, MD; Hein J.J. Wellens, MD, PhD
J Am Coll Cardiol. 2001;38(5):1355-1356. doi:10.1016/S0735-1097(01)01564-9
Exp Clin Cardiol. 2010 Summer; 15(2): e36–e44.
PMCID: PMC2898534
Clinical Cardiology: Review
aVR – the forgotten lead
Anil George, MD,1 Pradeep S Arumugham, MD,2 and Vincent M Figueredo, MD2,3
How are we doing on time and enthusiasm?
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