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Brugada criteria for distinguishing ventricular tachycardia from supraventricular tachycardia with aberrancy in wide-complex tachycardias.
Figure - A New Approach to the Differential Diagnosis of a Regular Tachycardia With a Wide QRS Complex. Posttraumatic stress disorder (PTSD) is a chronic and debilitating mental condition that develops in response to catastrophic life events, such as military combat, sexual assault, and natural disasters. Over the past several decades, considerable progress has been made in the development and empirical evaluation of assessment instruments for measuring trauma exposure and PTSD as well as related syndromes, such as acute stress disorder. This article, based on a comprehensive review by Weathers and associates,9 provides a selective and brief summary of trauma and PTSD assessments in adults. A comprehensive assessment of PTSD evaluates all of the diagnostic criteria, assesses associated features and comorbid disorders, and establishes a differential diagnosis. It is necessary to establish that an individual has been exposed to an extreme stressor that satisfies the DSM-IV definition of trauma as described in criterion A.
In addition to identifying an index event for symptom inquiry, it is important to assess for exposure to other traumatic events across the life span. The comprehensive Structured Clinical Interview for DSM-IV (SCID) is designed to help diagnose all the major DSM-IV disorders.12 As with all SCID modules, the PTSD module maps directly onto DSM-IV diagnostic criteria. Brugada Syndrome is an ECG abnormality with a high incidence of sudden death in patients with structurally normal hearts.
First described in 1992 by theA Brugada brothers, the disease has since had an exponential rise in the numbers of cases reported, to such an extent that the second consensus conference reported in 2005 that it was the second leading cause of death in males <40 (after trauma).
The other two types of Brugada are non-diagnostic but possibly warrant further investigation (see discussion below). Brugada type 3 can be the morphology of either type 1 or type 2, but with <2mm of ST segment elevation.
However this is controversial with much debate in the literature ranging from a very low threshold for EPS studies and ICD insertion (Brugada et al) to more conservative approaches.
Posterior infarctionA accompanies 15-20% of STEMIs, usually occurring in the context of an inferior or lateral infarction. Posterior extension of an inferior or lateral infarct implies a much larger area of myocardial damage, with an increased risk of left ventricular dysfunction and death. In patients presenting with ischaemic symptoms, horizontal ST depression in the anteroseptal leads (V1-3) should raise the suspicion of posterior MI.
Posterior infarction is confirmed by the presence ofA ST elevation and Q waves in the posterior leads (V7-9).


This picture illustrates the reciprocal relationship between the ECG changes seen in STEMI and those seen with posterior infarction. The degree of ST elevation seen in V7-9 is typically modest – note that only 0.5 mm of ST elevation is required to make the diagnosis of posterior MI! Marked ST elevation in V7-9 with Q-wave formation confirms involvement of the posterior wall, making this an inferior-lateral-posterior STEMI (= big territory infarct!). Note that there is also some inferior STE in leads III and aVF (but no Q wave formation) suggesting early inferior involvement. There are no dominant R waves in V1-2, but it is possible that this ECG was taken early in the course of the infarct, prior to pathological R-wave formation.
There are also some features suggestive of early inferior infarction, with hyperacute T waves in II, III and aVF.
With the eye of faith there is perhaps also some early ST elevation in the inferior leads (lead III looks particularly abnormal).
In RBBB, activation of the right ventricle is delayed as depolarisation has to spread across the septum from the left ventricle. The left ventricle is activated normally, meaning that the early part of the QRS complex is unchanged. The delayed right ventricular activation produces a secondary R wave (R’) in the right precordial leads (V1-3) and a wide, slurred S wave in the lateral leads.
Delayed activation of the right ventricle also gives rise to secondary repolarization abnormalities, with ST depression and T wave inversion in the right precordial leads. In isolated RBBB the cardiac axis is unchanged, as left ventricular activation proceeds normally via the left bundle branch. Sometimes rather than an RSR’ pattern in V1, there may be a broad monophasic R wave or a qR complex.
Tufts OCW material is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported License. However, in two subsequent reports in which a total of nine clinicians (two cardiologists, two emergency department clinicians, and five internists) used these criteria in interpreting a total of 168 WCTs that had been diagnosed with electrophysiologic testing, the sensitivity ranged from 79 to 92 percent, and specificity from 43 to 70 percent. In a comparison of the Brugada criteria and the Bayesian approach, the two approaches performed similarly, with sensitivities of 92 and 97 and specificities of 44 and 56 percent, respectively. The symptoms of PTSD are divided into 3 symptom clusters: reexperiencing, avoidance, and hyperarousal.
The measures that have been developed, including questionnaires, structured interviews, and psychophysiological procedures, have been extensively validated and many have been widely adopted internationally.
Although some of these tasks can be accomplished with self-report measures, most are best accomplished with a structured interview.


Exposure to multiple lifetime traumas is typical, and previous traumas may influence reactions to the index event.3,11 The target trauma is identified as the one that is currently causing the most frequent and severe symptoms. These include structured interviews, self-report measures, and multiscale personality inventories (Table 2). Posttraumatic stress disorder (PTSD) assessment instruments are psychometrically sound, can be used to collect information from multiple sources, and can be used to measure different trauma populations. Although structured interviews, self-report measures, and multiscale personality inventories are available for assessing PTSD, a structured interview is recommended to evaluate all of the diagnostic criteria, assess associated features and comorbid disorders, and establish a differential diagnosis. In addition to identifying an index event for symptom inquiry, it is important to assess patients for exposure to other traumatic events across their life span. In addition, the CAPS assesses criterion A by means of the Life Events Checklist, which screens for possible trauma exposure. One of the problems is that EPS are far from a gold standard, with aA negative predictive valueA of less than 50% and some studies suggest that we might be getting a little over-excited about this relatively recently described ECG finding.
Right bundle branch block, persistent ST segment elevation and sudden cardiac death: a multicenter report. Our Team, headed by Mike Cadogan & Chris Nickson, consists (mostly) of emergency physicians and intensivists based in Australia and New Zealand.
However, the lack of obvious ST elevation in this condition means that the diagnosis is often missed. Clinical interviews provide opportunities to ask follow-up questions, to clarify items and responses, and to use clinical judgment in making the final ratings. It also includes a trauma inquiry section that evaluates criterion A and identifies an index event for symptom inquiry. Over 60 different mutations have been described so far and at least 50% are spontaneous mutations, but familial clustering and autosomal dominant inheritance has been demonstrated.
Further study is necessary to confirm both the overall accuracy of this approach and its superiority to the Brugada criteria. In addition to evaluating the diagnosis and severity of PTSD, a comprehensive assessment often includes an evaluation for the presence of comorbid disorders and associated features. At the symptom level, the CAPS yields continuous and dichotomous scores for each item, and at the syndrome level it yields a continuous measure of overall PTSD symptom severity in addition to a dichotomous PTSD diagnosis.



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