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Okay. Hi, everyone that's joining us. Um We are six PM series waiting to give our teaching on E C G s tonight. Um I'll just give a couple of minutes just to let a few more people join. Um And then we'll far away and get going and just before we start as well, can everyone hear me speaking? Um Just put a little yes on the chat just to make sure that my microphone is working okay. That looks good. So I'll just give one more minute, let a few more people join and then we'll start the introduction. Okay. Hi, everyone. My name's Evie. I'm an F Y to doctor um part of the six PM series committee. Uh 6 p.m. series committee is a collective of UK based junior doctors who deliver teaching and have been doing so since just for the pandemic, um we are teaching mainly at clinical year medical students, but also to pre clinical year. And we've got some junior doctors that are interested in, in learning and watching my lectures too. Uh So spread the word to anyone else that you might think would be interested in our teachings. Uh we're doing a number of series and we have an Instagram and Facebook account to follow as well for some little snippets of medical knowledge here and there. Um So I will quickly introduce doctor is many who is A I M T two based on stroke at the moment moment in Hillingdon, who is well going to give us teaching tonight on E C G S. So I will hand over to as many. Now we go. Good evening everyone. Can you please, can you hear me? Can you just write? Yes, on the top if you can hear me? Perfect. OK. Thank you all for joining uh the 6 p.m. session on the C D T think. Um uh As if he said um my name is as many um one of the I M T twos at healing tongue at the moment working um in the stroke unit. Uh I was asked to give you uh teaching session on the talk on the E C T interpretation and uncommon clinical cases. So, in the next hour or so, um we will be going through how uh we'll be going through the basics of how to interpret any C G uh common clinical scenarios um and uh sport diagnosis that, you know, you have to um recognize on the city's. Uh I'm not gonna talk about cardiac electrophysiology as this is not the purpose of the session. So for your reference, this is a normal city before we go through how to interpret that or any abnormalities you might see on any city. Uh I'm gonna ask you question. So if you can use the pool to answer that. Uh So you're asked to record the 12 lady ct and which of the following options is the correct one? Um So V one is placed on the second in the second intercostal space in the right margin of the sternum. V two is placed in the fourth intercostal space. The left margin of sternum V three is placed in the fifth intercostal space in the midclavicular line. V four is placed midway between V two and V four. I'm gonna give you one minute to um answer the question. Okay. So I can see the answers. I see that most of you answered uh a ask the correct answer. Um So let's go through uh how we place the, the chest leads um uh for to, to record in the city. Um So this is the correct lead placement. Um The correct answer for the question I I asked you would be be um so V one is placed on the fourth intercostal spaces. You can see uh on the, on your screen at the right margin of the sternum V two is placed on the fourth intercostal space at the left side of the, of the sternum. Uh V four is placed on the fifth intercostal space in the midclavicular line. V three will go in between V two and V four, V five and V six is placed again in the 15th. The cost of space V V five is in the anterior Axillary line and V six in the midst um auxiliary line. Uh The uh the important thing to understand is that this lead placement allows us uh allows us the interpretation of specific areas uh of the heart. And, and that's why it's important, that's the, the leader placed correctly. And almost of the times you won't be asked to do that, but it's important to know. Um So for the easy did interpretation, um the first thing that I would give you is to always follow systematic approach. Um So uh these uh 10 steps is one of the approach that I would suggest you using starting by confirming the patient's details. It will not be uncommon to find easy this of a different patient inside your patient's notes, especially in hospitals that use still paper notes. And the second step would be to check the heart rates. Uh Then the heart written whether that this is a regular rhythm or an irregular rhythm, uh then assess the cardiac access uh and the P waves, uh then the pr interval, oh uh The curious complex, the ST segment T waves and then the QT interval. And so what I will try to do is I will try to go through all this and give you the, the things that you need to know about understanding every aspect of the CT and then we'll go through some cases. Another approach that you might be that you might see being used is the six states system to analyze in the city. And essentially by following this, uh, six state system, uh, you need to assess whether there is any electrical activity, whether, what is the heart rate again? Um What's their ill, whether this is, this is a regular or any regular rhythm? Then the curious complex, whether it's narrow or broad if there is electrical activity present. So there are P waves and if there, if there is electrical activity present, uh so P waves is this related to the ventricular activity. So you're curious complex and if it's related, then how it's related. And this is a more simplified approach to analyze an E C D. And you, you, you are taught that in courses like A L S and it's designed for people who don't have medical background percent. Um and other healthcare professionals to be able to detect growth abnormalities on the A C T s. Uh So, one of the very first things that you need to check when you interpret an E C G is whether the E C T machine has been calibrated correctly. So the printing, the printing speed for the paper should be a 25 millimeters per second. And it's merely volt uh electrical potential will cost 10 millimeter reflection on the city itself. So the is it's uh so the calibration spike should be one large uh square wide and two large large square store. And you can see that um on the corner of the uh the speed for the paper is important because according to that, we are able to actually calculate the heart rate by only using a few seconds of recorded electrical activity. Uh So remember that one large square is equal to 200 milliseconds and one small square is equal to 40 milliseconds. Now, let's talk about how to calculate uh the heart rate. Um There are different methods of uh assessing and calculating the heart rate on the A C T S. Uh I will mention to um methods that are commonly used, but please use whichever one you think suits you better. So the first method is the large square method. Um And here essentially their rate is equal to three hundred's are divided by the number of large squares between it's are are in terrible. Uh We have the number 300 because 300 large squares is equal to uh one minutes at paper spades at 25 millimeters per second. As we discussed, this is a use. This is a useful way to calculate the heart rate as um it's very quick, especially for regular reasons and uh other regular rate. Um Many people just remember uh these numbers on, on, on your, on the slides. So if there's one large square uh between the two ours. Um then you have a harder the three hundreds. If there are two large squares, heart rate of 1 50. if there are three large squares, 100 then 75 60 etcetera. Another method is the R wave method and the rates by using this method would be equal to the number of our waves on your rhythm strip. So on the bottom of your sed normally um times six. Um so the number of carbs complex is on, on the rhythm strip would give you the average rates over a 12th period, which is the normal um uh which is what the normal uh how normally re record the CT and, and this is useful for slow and irregular rhythms. If you're unsure whether what you have in front of you, it is a 12th periods, then you can always count 50 large squares and measure the uh check the number of our wave, our waves in, in the, in the 50 squares. And then uh multiply that by six. So according to that, if I ask you to um check the right on this. A CT um if you can answer the question by the pool. Okay, perfect. So I can see that the majority of you got this one. Um Correct. And so, well, I'm gonna use the bottom the rhythm strip. Um You can see here we have 2468, 10, 12 are waves on the 12th period and that would be around 72 BPM. Uh So, b is uh possibly the most right answer of all of them. Um So next thing um to assess when you check on the E C T is the cardiac access. Um So the cardiac axis represents the some of the polarization factors generated by individual cardiac monocytes. And this gives us an overall, uh this gives us an idea of the overall direction of the electrical activity. And it's important here to understand that we're talking about electrical activity and not the position of the heart. Uh And when would and what what women by electrical activity, women, the electrical potential during the deep polarization of the ventricles. So what when we discuss about cardiac axis, we mean QRS access. Uh um So for, for the purposes of that, um um it's important to understand that when the QRS is positive on a specific leads, which means more up and down, it means that the heart is depolarizing towards the late. If it's negative, it depolarizing away from the leads. And if it's I so electric, it depolarizing to 90 degrees to this late. The normal axis is uh the normal axis secures access between minus 32 plus 90 degrees. And so, since the left ventricle makes up most of the heart muscle under normal circumstances, uh the normal axis, as you understand, is directly directed downward slightly to the left um as a general rule, if lied one and aVF are both positive, then the access must be normal. I'm gonna talk to you about two ways to um to actually assess uh the, the axis. Uh But again, uh this is uh this is optional, you can use which everyone you prefer. So the first, the first way that I'm going to talk about is the three lead analysis. So this is a combined evaluation of leads 12 and three or aVF and this allows the rapid and accurate assessment of the access. Um So the most important thing to remember here is this diagram um that and you can see in how many degrees it's leads, uh it's limp lit uh is put and according to that, you can assess what is the summary of um of its leads in terms of how positive or negative they are and find your access in the table. You can see according to whether lied 12 and three Arabia are positive or negative or as electric. What is your access? Another way that I think allows a more precise estimation of the cardiac axis is the ice electric. Late in that way, the first step would be to find the most ice electric leads in your E C T. And I mean, the most electrical implicating on, on your A C C, then you will plot this mentally in your circle axis and and the direction of the access is perpetrated color to the ice electric access. So when you find this point, you check the direction and find the positive leads as your last step. So let's say, for example, that's your most eyes electrically is lead to on your sec. Um then you consider perpendicular point is aVL. So by taking, by checking if Avio is positive or negative, that will give you the answer as of whether um uh you have right axis deviation, um or um uh normal sluss, um left axis deviation and your E C T. So according to that, um let's answer this question if you can do it valuable. Uh So you have a 70 year old lady with pre motorist analysis and we're asking you what's the access and they say CC okay. So I, I can see that most of you got this from uh correct. So the correct answer here is right axis deviation. And let's go through why this is the right answer. So I'm gonna use the last method that I told you, I'm gonna find the most I see electric leads on the C C T and in the limply, it's the most days electric one I think would be uh lead to. So if we go back here uh finally to the most, the perpendicular 10.2, this one would be Aviall. So I need to check them whether Aviall is positive or negative. So if I go back to my E C T Aviall is negative here. So uh the the access is towards this direction. So I think we should we have right axis deviation if you follow this um this method. Um let's do another example again. Um So now you have a 70 year old lady with hypertension. What is the access on her E C T? Okay. Perfect. Uh So I can see again most of you got this one correct. Uh Here you have left axis deviation. I'm gonna go quickly through the answer. So um I will find again the most ice electrical eat. But I think in this case would be a VR. So if we go back to our diagram AVR, so uh my axis would be perpendicular to lead three in this case. Uh um So I need to check what's the direction of lead three? Um lead three here is negative. So I have so, so that means I will have left axis deviation. Uh So next step would be to assess the P wave. So the P wave represents the H O D polarization. A normal P wave has a smooth contour is monophasic and lead to buy physically in leeds V one. And it's important to remember that, that it's direction that it's upright in leeds, one and two and inverted in a VR. So if you see an inverted A via an inverted T wave in behavior, this is normal. The duration is also important to remember that it's less uh than three small squares. And the amplitude would be less than 2.5 millimeters in the link lits and less than 1.5 millimeters in the recording. Let's the HDL abnormalities are mostly seen in the inferior leads and elite V one as the P waves are most prominent in these leads on the screen. You can see the different morphology of the P waves according to whether there is uh right hmm enlargement, left, uh H H M enlargement or a combination of those two. Um Next thing is the pr interval. Uh So the pr interval is the time from the onset of the wave uh to the start of the cure is complex and that reflects the conduction through the ab node. Uh A normal P R N turbot is uh between 122 100 milliseconds that is equal to 3 to 43 to 4 to 5 small squares. Uh Here is very important to recognize any abnormalities. When we talk about prolonged period. In turbo, we, we talk about a V blocks. I'm not going to go through that. Now, we'll discuss that a bit later in the session when we talk about short parents turbos that suggest pre excitation. So the presence of an accessory pathway between the atria and the ventricles or a junctional written. Uh Next thing would be to assess the cure is complex. So the main features to consider here is the weight of the complex is whether it's narrow or broad. When we talk, when we talk about narrow curious complexes, we talk about super ventricular origin of uh of the urine. When we talk about broad complexes, most we mostly talk about ventricular origin of the rhythms and then uh band branch blocks um or uh a brand conduction conduction of super uh ventricular complexes. But I'm not going to go through that in details because it's not in the purpose of this session. Another thing to consider is the voltage. So the height of the complexes and we were mostly uh we mostly care about that when we talk about less ventricular hypertrophy. And there are several criteria to assess that as well. Um It's important here to remember that they cures complexes are usually um up to three small squares. So 7200 milliseconds. Next, we have the ST segment which represents the interpret between the ventricular depolarizations and re polarization. The main abnormalities to consider here is the ST elevation and ST depression um in uh situations like uh ST elevation, myocardial infection, um you have concave convex or uh obligatory straight ST elevation. Uh But another pathologist that might be different, you can see on the screen, the different causes of ST elevation and ST depression. And I'm only mentioning those, those things just so that you understand how important it is recognized if there are any ST segments pathologies. Um So I'm going to, I'm not going to go through that in more details. Uh The next thing is the T wave. So the T wave is the positive deflection after the after it's your, it's curious complex and it represents the ventricular re polarization. So it's important to remember that it's upright, it should be upright in or leads except a V R and B one again. Uh If there is inverted T wave in a V R or V one, this is a normal thing and it is expected the amplitude is less than five millimeters in the limb plates and less than 10 millimeters in the precordial leads. And uh the duration relates to the Q T in turbo in terms of T wave abnormalities and how to describe them. These are the uh six main abnormalities that A T wave might have. Next thing. Uh and last to check um as a basic thing on your E C T interpretation is the QT interval, which is the time from the start of the Q wave to the end of the T wave that represents the time taking for the ventricular depolarizations and Repola re polarization. And here it's important to remember that um the corrected uh what, what we need to do is to uh to assess what is the corrected QT uh interval because that gives us that estimates the QT interval at the standard heart rate of 60 BPM. And that allows comparison of acuity values over time at the different heart rate and also it improves uh the direction of patient's that are higher risk of arrhythmias. Uh There are multiple formulas that you can use to uh to estimate the Q T C. Uh The opposite formula is the one that is most commonly used. You, I'm sure that you are all familiar with uh your med calculators. You can always put the numbers that and calculated um in terms of numbers, it's important to remember that Q T C values more than 100 440 milliseconds in men and 460 million seconds in women is consistent with prolonged to T C S and Q T C. Less than 350 milliseconds is consistent with sort UTC and the cause of prolonged UTC. Um You can see them on the screen. Uh And it's important to recognize um uh this patient and correct any reversible causes uh so that you prevent your patient from having a catastrophic arrhythmia. Um So, um these were the basics of the sec interpretation. So for the next half an hour, we're gonna go through some case based discussion. Um On that point, what I want to say is that it's always very important to assess and the CDC in relevant clinical context. Um And not just by looking at the CDC, sometimes it's uh you have a spot diagnosis and it's very easy to assess the abnormality, but in most of the cases, you need a relevant clinical history in order to make sense of what you see on the CDC. So first case, um, you have a 55 year old lady who presents with populations, she reports that her symptoms started three days ago. She decides to come to the hospital is now, so started having some chest tightness. Uh, she doesn't have any past medical history and she's not on any regular medications. Her observations as you can see on the slides, BP is 110 over 60. Her heart rate is 100 and 30. Um her sats 97 on air and she's a febrile. Her blood are unremarkable and her troponin is fifth from 15, has gone up to 17. This is her E C G. I'm going to give you a minute to have a look at that and this is the question that um we, we ask you. So according to the history in the city, what is the diagnosis here? Is this patient having an inferior? Am I? Is this an HBO flatter? Is this S V T? So super ventricular tachycardia, is this an age of fibrillation with a rapid ventricular response or is this patient just anxious? I'm just going to go back to the E C D. It's me if I wonder if you could put the options up again. I know maybe flip back between cause I've just put a T E. Thanks. So these are the options. Um I can go back to the E C T if you want me to, please let me know on the chat whether you want to see the CT one more time. Okay. With basic to one more time. Okay. I'm going to go through the answer. I think most of you um got this correct. So the correct answer would be D um So this is the nature fibrillation with a rapid ventricular response. Um the main tip, but I can give you to in order to recognize uh nature fibrillation with a rapid ventricular response. First, assess whether there are any P waves. If there are no obvious P waves, then um you, you probably don't have a uh everything coming from there. Um From sinus uh note, um you can see that the a rhythm here is quite irregular and it's irregularly regular. What is the definition of age of fibrillation? And it's quite fast, it's around 100 and 30. Uh So this would be consistent with uh age of fibrillation with a rapid ventricular response. And with regards to the other options, I uh the only other one that we could potentially um consider would be a true flatter and with a variable block potentially, but we can't see any obvious flatter waves. Um So I think the most, the most possible answer for this one would be a f with rubber ventricular response. Um Next case we have a 67 year old gentleman who presents with a two hour history of central chest pain radiating to his left arm. Uh He's has a background of hypertension and he's a smoker. Um These are his observations requires uh remarkable. His BP is a bit low considering the fact that he's someone with hypertension, his blood was still not back. And on assessment, he appears to be very sweaty and in pain and he reports that his pain is now nine out of 10 and it was seven out of 10 when it started. So this is his A C T. We're gonna give you just a few seconds to look at it and then I'm going to go through the options. So what is the diagnosis here? Is this patient having pericar diabetes? Is this uh stemi? So, uh my card uh infection with ST elevation. Is this a non stemi? Is this a complete heart block or is this anxiety? I'm gonna go back to the E C T again. I'm gonna give you the options one more time, have a look one more time on the E C T. So these are the answers. Okay? I think most of you have responded now. Um So the correct answer is indeed be. So this is a stemi um You can see here that we have the main abnormality in the C C D is ST elevation in leads to three and aVF it's all the inferior leads. Um So um here you correctly recognized stemi. Um So, uh the next question we would have is um so the patient is urgently transferred for primary PCI. Uh But the next question is which of the coronary arteries is blocked? Okay. So, most of you um responded that uh the coronary artery that's blocked is the right coronary artery, which is the correct answer. Um So, for, for uh this question is always important to remember the coronary arteries and the relation to the CDC leads. So, um the right coronary artery um uh is uh is affected when the inferior leads. So 23 and aVF um I have the pathology, the circumflex artery uh plays a role when we have the lateral, the lateral wall of the heart. So leads one V five and B six. Um and then the left anterior descending artery um is corresponding to the anterior wall of the heart. So we want to be four. Um This is a common question on exams as well. So, uh I thought it would be important for you to remember that. Uh Next case, you have your culture of, you know, an 86 year old gentleman who's admitted for UTI five days ago, he's not feeling very dizzy. Um In terms of background, he has hypertension type two diabetes, uh BPH and ischemic heart disease. His observations, BP is a bit on the high side, 1 50 or 80. His heart rate is fluctuating actually between 30 and 50 bit more minutes. Uh, um, he's a fa brow and, uh, he's, uh, he sat, uh, he sat and 95% rumor with the rest of 15. Uh, he loved her blood this morning. Um, and things were getting better from the infection point of view. He's a bit anaemic. Um, but you decide to do any ct, given his low heart rate and this is his E C T. So the question is, what is the main problem here? What's the, the diagnosis? And I'm gonna give you the options? And is this the first degree heart block? Is this a sinus bradycardia? It is a complete heart block. Is this morbid one A V block or more bids to 80 block? I'm gonna leave the options for a few seconds and then I'm going to go back to the E C D. Yeah, I'm going to give you the options one more time and have a look at the CT one more time. Okay. So, um I'm going to go through the answer. The answer in this city is that this is a complete heart block. I understand it's a bit tricky. Um So what you need to assess here is whether there is any uh atrial activity. So if there any P waves, I know it's difficult. It's not a great the city, but there are P waves if you go to your view and you can see the P waves here. And then you need to assess whether there is a ventricular activity and you can see clearly your tourist complexes. Uh The next important thing here is to assess whether there is any correlation between the P waves and the QRS is. And if there is what, what's the relation relation? What I usually do is just take a plain piece of paper with pen and then plot the atrial activity and then the ventricular activity and see if there's any correlation between themselves. Or if if or if there is uh no correlation at all in this cc'd, there's no correlation at all with between atrial and ventricular activity. And that's why it's consistent with a complete heart block. Um So second question here, we said this complete heart block, what would be the most appropriate management for this patient? Does this patient needs a pacemaker insertion? Um Is the next option would be to do nothing. That because this is a benign rhythm option. C would be to give only entrepreneur, the patient is symptomatic, but the pacemaker would not be, would not be required. And uh fourth option would be to only stop the medications and that uh block the heavy note, no further action is needed. Um Someone is asking how old is the patient and the patient is 86 years old. Um So I I can see on your chat, you want to see the case again and can you tell me exactly what you want from the case, you want the history or um the problem. So we have an 86 year old gentleman who comes because of a uti, he's found to be very dizzy and bradycardic, we do an E C D and the CT is consistent with a complete heart block. The question is, what is the appropriate management for this patient? Has a complete heart block? Okay. Um So I'm just gonna go through the answer. Yes. The correct answer is a, the patient will need a permanent pacemaker. So complete heart block and more bits do. So the these are high degree heart blocks, you can't just leave them, you can't leave the patient without pacemaker, uh because that's uh eventually they will arrest and die. Uh So for a patient who comes with a complete heart block, even if that is an intermittent, complete heart block, you always have to send that for pacemaker insertion. So you can't just stay and uh do not think you obviously you should stop the medications uh block the heavy note. But since someone got into complete heart block, then there's no way back. Unfortunately. So I'm just gonna go through the A V blocks very quickly. Um So remember that uh if the, if the are is very far from p then you have first degree. So if you have prolonged p uh prolonged pr only, but there's always a curious following every um P wave, then you have first degree heart block and first degree heart block can be completely symptomatic and benign. There's nothing to do about this is just something that it's there and we need to be aware. Um Some patient's will let you know that, you know, uh someone told me I have this and then the next one is uh working back or uh more bids one. So, um moments, one, you have um P waves. Uh So you have P waves before every curious until, until uh until you have a drop bit. Uh But it's P R gets longer and longer. Um And that is the working back phenomenon. So you can see on the C C T you have pr pr intervals that are getting longer until after a pr you drop a bit. And the next is more bids to uh where essentially you have P R S that are consistent and then, then at some point A P uh after a P wave, you won't have ventricular activity. Um and you can have it in complexes. So by Gemini trigemini, um and then the, the complete heart block that we have already discussed about. This is another example of a complete heart block. You have atrial activity and ventricular activity with no uh nothing to do with each other. They're not responding to one another. So the peace and Q's don't agree, you have third degree uh us around to remember. Um So next case you have a 55 year old lady who's found unresponsive in the park. You don't know anything about her past medical history. Uh She has no pulse. When the ambulance uh crew arrive, they start CPR, they start chest compressions and monitor accordingly as for the LS protocol and she's taken to the nearest A N A and this is her E C G. So this is another example of spot diagnosis uh that you have to be able to recognize and when we're going to give you the options. So what does the, is it is? So, is this an atrial flutter? Is this monomorphic PT is this V F? So ventricular fibrillation is this or Saadiq one or is this a super ventricular tachycardia? Mhm I'm gonna show you the CT one more time. Okay. So I'm just going to go through the uh correct uh answer. So the correct answer here is monomorphic ventricular tachycardia. And this, the city is very characteristic of that. You can see that you can't identify essentially P waves here. You have this very, very broad curious complexes with uh unique morphology and this is, it is very consistent with ventricular tachycardia. And so based the correct answer and my next question would be, so you want to see the answers again? I just went through the, the answer. Yeah. B is the correct answer for the for this question. Um So the next question would be, can't this written be found in a person who has oppose. What do you think? Yes or no. Okay. So actually, yes, this, this rhythm can be found in a person who has a pulse. Um I'm not sure how long the patient who has, what we call the sustained ventricular tachycardia will have a pulse for. But it is, it can be found um the management in uh in a person who has a pulse and a and a person who doesn't have a pulse uh is obviously different. Um But it's important to remember that, uh especially when you, we assess someone who doesn't have a pulse. Uh It's important to say that they have a pulseless ventricular tachycardia because it's something that can be found in someone with a pulse. So I'm going to go through the last case. Um So we have a 60 year old lady with who presents now with severe populations that started two hours ago and she has a background of high BP and type two diabetes. Uh These are her medications is on amLODIPine 5 mg once a day and with four and 500 mg twice a day. Um, her BP is 110 over 70. Her heart rate is quite high, one at 1 50 BPM. Um See her respiratory rate is 18, her sudden 98 in room air temperature is 36.5. Her blood are still not back and her chest X rate doesn't show anything uh anything remarkable? So this is her E C D and, and the question here is according to the history in the E C T, what is the problem with this patient? Is this a sinus tachycardia? Is this an atrial fibrillation? Is this a 2 to 1 atrial flutter? Is this a super ventricular tachycardia or is this a junctional written? I'm just gonna keep the options for a few seconds and then I'm going to go back to the E C T so that you can have another look. Let's go back to the E C T. I'm going to show you the options again and they used to do one more time. Okay. I'm going to go through the answer now. Um So, uh the correct answer is that this is a super ventricular tachycardia as most of you correctly set. Um So, the important thing with this is it is to, first of all recognize that this is quite high heart rate. So um it's around 1 50 BPM and you, you can't see any clear P waves. Um there's no P wave. So that means that um uh it does not come from the sinus. Um And the fact that you have the QRS complex is that are similar and uh they're quite narrow. It means that comes from somewhere above the ventricle. So that means super ventricular origin of the, of this written and this is consistent with the super ventricular tachycardia. So you decide to treat the patient a supraventricular tachycardia, some of that um OK, stable, you're treated with some of dentist in as per your guidelines. Uh sermons medically stable. She's been reviewed by the cardiology team and see is discharged on by. So, prolol 5 mg um with uh echocardiogram that's so normal uh left ventricular ejection fraction. So also goes home. Uh two months later, she represents to the emergency department with chesty cough and fevers. Uh She's been reviewed by the E D doctors who started on treatment for um a lower tract respiratory infection. Um And uh you're asked to review her E C T. So, um the options are, is the easy tea that I will show you in a minute. A super ventricular tachycardia. Is it a junctional rhythm reduction of bradycardia, normal sinus rhythm, atrial flutter or atrial fibrillation? And this is the E C T that you have this time. I'm gonna give you the options one more time and that's the E C T again. Okay, perfect. So I think most of you got this one correct and this characteristic is city of 4 to 1 flatter with a characteristic uh shorted waves. Um and these morphology um so yes, this is consistent with eight or flatter. And so I think these were the scenarios I had to tell you about. Uh So I'll take home messages from this session. Um Try to follow with a systematic approach when you review in the city um As a general advice, the Morris, it is, you review the better. I know it's difficult initially, but you'll get used to reviewing. Is it is be familiar with the common, is it, is that you can come across and if, if, if you're in doubt, always ask because that's the only way you will actually learn. And so as they suggested resources for a CT and these are the ones I usually um look at. So if you want a good introductory guide for the CT, the CT made easy is a good one. Life In The Fast Lane is always a very good website that you can use. Uh Many of my slides were taken from Life in the Fast Lane and the CT Academy is a good website with uh videos to go through. And thank you all very much for attending the session. Please uh feel in the uh feedback form because it will be important for us to understand if you felt this presentation was useful, whether you found it easy, difficult or appropriate and um do more sessions for you. Uh That's um uh will be good. Yeah. So it's many, I don't think we've met, but that's okay. Uh If you had to leave, that was excellent. I learned a lot as a surgical trainee. So fantastic. Thank you so much. Thank you very much. That's great to hear. Yeah, it was a great refresher and you know, we'd love to have you again. A very, very nice pace. Uh So, uh yeah. No, it was, uh it was, it was very, very good and I hope everyone else enjoyed it guys. Uh We've got some more great sessions plan just, you know, keep the feedback coming. Uh We have this available on catch up as well. Uh So it'll be live and in fact, we're one of the biggest uh teaching organizations uh here on Medal. So we're going to try and ramp that. I'd like to bring our lectures as well. Um We're trying to make everything thing that we do from now on catch up. Um And uh I had helps everyone that, you know, to have the flexibility to watch this stuff again and uh be able to really consolidate their learning. Yeah, that's uh that's it. Uh I think we can call it a day. Um Cool, perfect. Thank you very much everyone. Thank you. Bye bye bye.