The Proper Interpretation of Tachycardias The Proper Interpretation of Tachycardias Breaking through the barriers Breaking through the barriers

The Proper Interpretationof Tachycardias

The Proper Interpretationof Tachycardias

Breaking through the barriersBreaking through the barriers

Raymond L. Fowler, M.D., FACEP

Raymond L. Fowler, M.D., FACEP

Associate Professor of Emergency MedicineAssociate Professor of Emergency MedicineThe University of Texas SouthwesternThe University of Texas Southwestern

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Deputy EMS Medical DirectorDeputy EMS Medical DirectorThe Dallas Metropolitan BioTel SystemThe Dallas Metropolitan BioTel System

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Co Chief in the Section onCo Chief in the Section onEMS, Disaster Medicine, and Homeland SecurityEMS, Disaster Medicine, and Homeland Security

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Past PresidentPast PresidentNational Association of EMS PhysiciansNational Association of EMS Physicians

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Associate Professor of Emergency MedicineAssociate Professor of Emergency MedicineThe University of Texas SouthwesternThe University of Texas Southwestern

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Deputy EMS Medical DirectorDeputy EMS Medical DirectorThe Dallas Metropolitan BioTel SystemThe Dallas Metropolitan BioTel System

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Co Chief in the Section onCo Chief in the Section onEMS, Disaster Medicine, and Homeland SecurityEMS, Disaster Medicine, and Homeland Security

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Past PresidentPast PresidentNational Association of EMS PhysiciansNational Association of EMS Physicians

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www.utsw.wswww.utsw.wswww.utsw.wswww.utsw.ws

www.rayfowler.comwww.rayfowler.com

Thoughts for the Day:Thoughts for the Day:

•I was thinking that women should put pictures ofmissing husbands on beer cans!

•If it’s true that we are here to help others, thenwhat exactly are OTHERS here for?

•How much deeper would oceans be ifsponges DIDN’T live there?

•If a cow laughed, would milk come out her nose?•Why don’t they just make MOUSE flavored cat food?•How come ABBREVIATED is such a long word?•I just got skylights put in my place…and the

people in the apartment above me are FURIOUS!•So, what’s the speed of “DARK”?

•I was thinking that women should put pictures ofmissing husbands on beer cans!

•If it’s true that we are here to help others, thenwhat exactly are OTHERS here for?

•How much deeper would oceans be ifsponges DIDN’T live there?

•If a cow laughed, would milk come out her nose?•Why don’t they just make MOUSE flavored cat food?•How come ABBREVIATED is such a long word?•I just got skylights put in my place…and the

people in the apartment above me are FURIOUS!•So, what’s the speed of “DARK”?

The emerging ofa subspecialty:

The emerging ofa subspecialty:

ParamedicineParamedicine

Approaching thePatient

Approaching thePatient

“See what you see!”“See what you see!”

““People look, but theyPeople look, but theydon’t see”don’t see”

……A. Fowler, Jr.A. Fowler, Jr.

““People look, but theyPeople look, but theydon’t see”don’t see”

……A. Fowler, Jr.A. Fowler, Jr.

Alertness? Level of distress?Noises?Respirations?The pulse rate?Skin?Obvious things (bleeding)

Alertness? Level of distress?Noises?Respirations?The pulse rate?Skin?Obvious things (bleeding)

The most common signof illness . . .The most common signof illness . . .

Elevated pulse rateElevated pulse rate

What normally acceleratesthe pulse rate?

What normally acceleratesthe pulse rate?

EpinephrineEpinephrine

Specifically:In response to stress,

epinephrine is releasedfrom the adrenal glandsmaking the heart beat

stronger and faster

Specifically:In response to stress,

epinephrine is releasedfrom the adrenal glandsmaking the heart beat

stronger and faster

Signs of ShockSigns of Shock

Weak, thirsty, lightheadedPale, then sweaty

TachycardiaTachypnea

Diminished urinary output

Weak, thirsty, lightheadedPale, then sweaty

TachycardiaTachypnea

Diminished urinary output

HypotensionAltered LOC

Cardiac arrestDeath

HypotensionAltered LOC

Cardiac arrestDeath

EarlyEarly

LateLate

What does a lowWhat does a lowblood pressure mean?blood pressure mean?

What does a lowWhat does a lowblood pressure mean?blood pressure mean?

EitherEither......EitherEither......

•Loss of volumeLoss of volume•Low cardiac outputLow cardiac output•Increased vascularIncreased vascular

spacespace

•Loss of volumeLoss of volume•Low cardiac outputLow cardiac output•Increased vascularIncreased vascular

spacespace

Or a combinationOr a combinationof any of theseof any of these

…from BTLS, editions 2, 3, 4, and 5 Fowler et al…from BTLS, editions 2, 3, 4, and 5 Fowler et al

ShockShock

CardiogenicRapid pulseDistended neck veinsCyanosis

CardiogenicRapid pulseDistended neck veinsCyanosis

Volume LossRapid pulseFlat neck veinsPale

Volume LossRapid pulseFlat neck veinsPale

VasodilatoryVariable pulseFlat neck veinsPale or pink

VasodilatoryVariable pulseFlat neck veinsPale or pink

Our pulse can only go so fast under sympatheticstimulation:

Our pulse can only go so fast under sympatheticstimulation:

220 minus age220 minus age

Baby = (220 – 0) = 220

Snerd = (220 – 53) = 167

Aunt Minnie = (220 – 70) = 150

Baby = (220 – 0) = 220

Snerd = (220 – 53) = 167

Aunt Minnie = (220 – 70) = 150

Put another way:Put another way:

Our pulse rates canonly go as fast as

epinephrine can makethem go...

Our pulse rates canonly go as fast as

epinephrine can makethem go...

…unless there is a conduction abnormality

…unless there is a conduction abnormality

So, REALLY . . .So, REALLY . . .

. . . ya got SINUS TACH . . .. . . ya got SINUS TACH . . .

. . . and everything else . . . and everything else

Sinus TachSinus Tach

oror

PSVT, Afib, Aflutter, MAT, or VTachPSVT, Afib, Aflutter, MAT, or VTach

THE ONLY PROBLEMIS TELLING THEDIFFERENCE!!

THE ONLY PROBLEMIS TELLING THEDIFFERENCE!!

Many medics are not adept

at EKG interpretation

WHY???

Many medics are not adept

at EKG interpretation

WHY???

Because many EKG courses are too long, too boring,

and teach difficult conceptsto medics

who will never use that information

Because many EKG courses are too long, too boring,

and teach difficult conceptsto medics

who will never use that information

Rhythm Strip InterpretationRhythm Strip Interpretation

Anatomically

Anatomicallyspeaking...

speaking...

Anatomically

Anatomicallyspeaking...

speaking...

1856 - First action potential described by von Koelliker and Muller

1887 - First EKG by Waller recorded on a lab technician named Thomas Goswell, in London

1893 - Einthoven introduces the term ‘electrocardiogram”

1895 - Einthoven names P QRS and T

1905 - Einthoven starts transmitting EKG’s from the hospital to his laboratory 1.5 k away via telephone cable, the first one on 3/22, the first ‘telecardiogram’

1910 - First American review of EKG’s, by James at Columbia and Willaims at Cornell

1912 - Einthoven described the Leads 1, 2, 3, later called Einthoven’s triangle”

1920- Pardee publishes the first EKG of an acute MI, describing the T wave as being tall and “starts from a point well up on the descent of the R wave”

1924 - Einthoven wins the Nobel for inventing the EKG

1932 - Wolferth and Wood describe the clinical use of chest leads

1938 - The AHA and the Cardiac Society of Great Britain define the standard positions, and wiring, of the chest leads V1 – V6

1942 - Emanuel Goldberger adds the augmented limb leads avR, avL, and avF to Einthoven’s three limb leads, making the first 12 lead EKG

1856 - First action potential described by von Koelliker and Muller

1887 - First EKG by Waller recorded on a lab technician named Thomas Goswell, in London

1893 - Einthoven introduces the term ‘electrocardiogram”

1895 - Einthoven names P QRS and T

1905 - Einthoven starts transmitting EKG’s from the hospital to his laboratory 1.5 k away via telephone cable, the first one on 3/22, the first ‘telecardiogram’

1910 - First American review of EKG’s, by James at Columbia and Willaims at Cornell

1912 - Einthoven described the Leads 1, 2, 3, later called Einthoven’s triangle”

1920- Pardee publishes the first EKG of an acute MI, describing the T wave as being tall and “starts from a point well up on the descent of the R wave”

1924 - Einthoven wins the Nobel for inventing the EKG

1932 - Wolferth and Wood describe the clinical use of chest leads

1938 - The AHA and the Cardiac Society of Great Britain define the standard positions, and wiring, of the chest leads V1 – V6

1942 - Emanuel Goldberger adds the augmented limb leads avR, avL, and avF to Einthoven’s three limb leads, making the first 12 lead EKG

Einthoven1912

Einthoven1912

Goldberger 1942

Goldberger 1942

AHA and Cardiac Society of Great Britain 1938

AHA and Cardiac Society of Great Britain 1938

SASA

AVAV

Bundle of HisBundle of His

Bundle BranchesBundle Branches

Heart Electrical Conduction Heart Electrical Conduction

RhythmStripInterpretation

RhythmStripInterpretation

RateRhythmPPRQRSSTTUAssessment

RateRhythmPPRQRSSTTUAssessment

Basic InterpretationBasic Interpretation

•Rate•Rhythm•P Waves•PR Interval•QRS Complex

•Rate•Rhythm•P Waves•PR Interval•QRS Complex

•ST Segment•T Wave•U Wave•Summarization

•ST Segment•T Wave•U Wave•Summarization

RateRate

RhythmRhythm

Axis

Hypertrophy

Infarction

Axis

Hypertrophy

Infarction

P

PR

QRS

ST

T

U

Assessment

P

PR

QRS

ST

T

U

Assessment

The first thingyou do is

to perform a “primary survey”of the EKG strip

The first thingyou do is

to perform a “primary survey”of the EKG strip

Speaking of rate, I have found thatbeing able to boogie makes a big difference in being able to tell one rhythm from another

Speaking of rate, I have found thatbeing able to boogie makes a big difference in being able to tell one rhythm from another

I mean. . .if you ain’t gotrhythm, what you gonna do?I mean. . .if you ain’t gotrhythm, what you gonna do?

IMPORTANT:IMPORTANT:

•Sinus tachycardia with a rate of 150 or aboveSinus tachycardia with a rate of 150 or aboveand PAT/PSVT look very similarand PAT/PSVT look very similar

•PAT/PSVT are not usually life threatening PAT/PSVT are not usually life threatening except in the rare setting of a except in the rare setting of a patient having myocardial ischemia patient having myocardial ischemia (chest pain, diaphoresis, or dyspnea)(chest pain, diaphoresis, or dyspnea)



Even More Important:Even More Important:

•When you can’t tell if a rhythm isWhen you can’t tell if a rhythm issinus tachycardia or PAT/PSVT,sinus tachycardia or PAT/PSVT,be wary of the more serious causebe wary of the more serious cause

•It may be difficult, or even impossible,It may be difficult, or even impossible,to see any irregularity in very fast to see any irregularity in very fast atrial fibrillationatrial fibrillation

•When you can’t tell if a rhythm isWhen you can’t tell if a rhythm issinus tachycardia or PAT/PSVT,sinus tachycardia or PAT/PSVT,be wary of the more serious causebe wary of the more serious cause

•It may be difficult, or even impossible,It may be difficult, or even impossible,to see any irregularity in very fast to see any irregularity in very fast atrial fibrillationatrial fibrillation

The most common causeof tachycardia in Parkland ER

is probably albuterol……followed by

amphetamine, cocaine,sepsis, DKA…

The most common causeof tachycardia in Parkland ER

is probably albuterol……followed by

amphetamine, cocaine,sepsis, DKA…

The most common causeof bradycardia in Parkland ER

is probably beta blockers…

…probably ISN’T greatphysical conditioning…

The most common causeof bradycardia in Parkland ER

is probably beta blockers…

…probably ISN’T greatphysical conditioning…

The incidence of bradycardia

post-hemorrhage,especially

intraperitoneally,is published to be

as high as 7 to over 20%

The incidence of bradycardia

post-hemorrhage,especially

intraperitoneally,is published to be

as high as 7 to over 20%

Always explain a tachycardia...

Corollary:Corollary: Don't depend on the presence of a tachycardia to determine that

an emergency is present

Always explain a tachycardia...

Corollary:Corollary: Don't depend on the presence of a tachycardia to determine that

an emergency is present

Sinus Tachycardia:

A “physiological response”

Sinus Tachycardia:

A “physiological response”

Remember:

The Maximum Sinus Tachycardiafor a patient is

about 220 - age

Remember:

The Maximum Sinus Tachycardiafor a patient is

about 220 - age

What is this rhythm?What is this rhythm?

Correct answer:“It COULD be sinus tach”

Correct answer:“It COULD be sinus tach”

220 – 55 = 165220 – 55 = 165

If you forget everythingelse that I say:

Remember that Remember that patients havingpatients havingnear maximumnear maximum

sinus tachycardiasinus tachycardiaat restat rest

are dying!are dying!

If you forget everythingelse that I say:

Remember that Remember that patients havingpatients havingnear maximumnear maximum

sinus tachycardiasinus tachycardiaat restat rest

are dying!are dying!

Hemorrhagic shockSepsis

TensionTamponade

Ruptured aortaRuptured ectopic

Massive P.E.

Hemorrhagic shockSepsis

TensionTamponade

Ruptured aortaRuptured ectopic

Massive P.E.

Something Something mobilizing amobilizing a

massivemassivephysiological physiological

responseresponse

Something Something mobilizing amobilizing a

massivemassivephysiological physiological

responseresponse

Your job isto determine ifa rapid rhythm

MAY be sinus tach

Your job isto determine ifa rapid rhythm

MAY be sinus tach

If it is, If it is, you must take actionyou must take action

If it is, If it is, you must take actionyou must take action

What is this rhythm?What is this rhythm?

220 – 60 = 160220 – 60 = 160

Correct answer:“This HAS to bean arrhythmia

Correct answer:“This HAS to bean arrhythmia

RegularityRegularity

Is there Regular

Irregularity or

IrregularIrregularity?

Is there Regular

Irregularity or

IrregularIrregularity?

Is there Regular

Irregularity:

•Bigeminy/Trigeminy•Wenckebach

The “guy with a limp”The “guy with a limp”

Is there Regular

Irregularity:

•Bigeminy/Trigeminy•Wenckebach

The “guy with a limp”The “guy with a limp”

RegularIrregularity:

•Bigeminy/Trigeminy

Underlying sinus rhythmUnderlying sinus rhythmwith PVC’s regularlywith PVC’s regularly


•Bigeminy/Trigeminy

Underlying sinus rhythmUnderlying sinus rhythmwith PVC’s regularlywith PVC’s regularly

BigeminyBigeminy


•Wenckebach

Sinus rhythm with Sinus rhythm with progressive prolongation progressive prolongation

of PR until dropped P waveof PR until dropped P wave


•Wenckebach

Sinus rhythm with Sinus rhythm with progressive prolongation progressive prolongation

of PR until dropped P waveof PR until dropped P wave

WenckebachWenckebach

IrregularIrregularity:

•Atrial Fibrillation•Variable Atrial Flutter

•MAT•Ectopy

The “stumbling drunk”The “stumbling drunk”


•Atrial Fibrillation•Variable Atrial Flutter

•MAT•Ectopy

The “stumbling drunk”The “stumbling drunk”


•Atrial Fibrillation

Irregularly irregular,narrow complex,chaotic baseline


•Atrial Fibrillation

Irregularly irregular,narrow complex,chaotic baseline

Atrial FibrillationAtrial Fibrillation

Appears almostregular on thissmall portion ofthe strip

Appears almostregular on thissmall portion ofthe strip

A look ata larger strip

reveals theirregularity

A look ata larger strip

reveals theirregularity


•Multifocal AtrialTachycardia

Irregularly irregular,narrow complex,

three or more P waves


•Multifocal AtrialTachycardia

Irregularly irregular,narrow complex,

three or more P waves

Multifocal Atrial Tachycardia

Multifocal Atrial Tachycardia


•Ectopy

Underlying sinus rhythmdisturbed by

PAC’s (narrow)or PVC’s (wide)


•Ectopy

Underlying sinus rhythmdisturbed by

PAC’s (narrow)or PVC’s (wide)


•Atrial Flutter withVariable Block

Sawtooth Baseline withVarying Ventricular

Response


•Atrial Flutter withVariable Block

Sawtooth Baseline withVarying Ventricular

Response

Atrial Flutter withVariable Block

Atrial Flutter withVariable Block

Atrial Flutter withHigher Grade BlockAtrial Flutter with

Higher Grade Block

Regular•Sinus Tach

•PSVT•Aflutter with fixed block

Narrow complex,very regular and fast


•PSVT•Aflutter with fixed block

Narrow complex,very regular and fast


Narrow complex,usually see P waves,

defined by >100,Remember 220 – age!


Narrow complex,usually see P waves,

defined by >100,Remember 220 – age!

Sinus TachSinus Tach

Sinus Tachwith LBBBSinus Tachwith LBBB

Regular•PSVT

Narrow complex,often don’t see P waves,

typically >150,perhaps over 200

Regular•PSVT

Narrow complex,often don’t see P waves,

typically >150,perhaps over 200

Paroxysmal Supraventricular

Tachycardia

Paroxysmal Supraventricular

Tachycardia

Speaking of AdenosineSpeaking of Adenosine

…but just when we thought life was getting easier…

…but just when we thought life was getting easier…

Advanced Cardiac Life SupportAdvanced Cardiac Life Support

•…is commendable for its continuedsearch for the science ofemergency cardiac care

•…but, misses the boat in terms oftelling us how to assess tachycardia in a rememberable manner

•…is commendable for its continuedsearch for the science ofemergency cardiac care

•…but, misses the boat in terms oftelling us how to assess tachycardia in a rememberable manner

Advanced Cardiac Life SupportAdvanced Cardiac Life Support

It is insufficient to simply say“are the signs or symptoms

due to tachycardia?”or

“Rate-related signs and symptoms occur at many rates, seldom < 150 bpm”

It is insufficient to simply say“are the signs or symptoms

due to tachycardia?”or

“Rate-related signs and symptoms occur at many rates, seldom < 150 bpm”

Unstable TachycardiasUnstable TachycardiasThe ACLS StatementThe ACLS Statement

…it doesn’t sayEXAMINE THE PATIENT!

…it doesn’t sayEXAMINE THE PATIENT!

““Establish rapid heart rate as Establish rapid heart rate as cause of signs and symptoms”cause of signs and symptoms”

““Rate related signs and Rate related signs and symptoms occur at many rates”symptoms occur at many rates”

What is the ambient temperature?

What is the ambient temperature?

What is the patient’s blood pressure?

What is the patient’s blood pressure?

Remember:Remember:

If you find a patient with a tachycardia,The first question to ask is

“could this be a sinus tachycardia”!

If you find a patient with a tachycardia,The first question to ask is

“could this be a sinus tachycardia”!

Of course, if the patient is on the monitor andyou see THIS…..

Of course, if the patient is on the monitor andyou see THIS…..

Remember too:Remember too:

80% of Wide Complex Tachycardiaswill be VTach

The rest will be sinus tach with abundle branch block

80% of Wide Complex Tachycardiaswill be VTach

The rest will be sinus tach with abundle branch block

Evaluation of TachycardiaEvaluation of Tachycardia

Ventricular rate over 100Ventricular rate over 100

Max sinus = 220 - ageMax sinus = 220 - ageWhat is the

patient’s maximum expected

sinus tachycardia?

What is the patient’s maximum

expectedsinus tachycardia?

Is it fast?(If so, keep going)

Is it fast?(If so, keep going)

If so, rule out and/ortreat cause(s),

such a hypovolemia, sepis, and other

shock states

If so, rule out and/ortreat cause(s),

such a hypovolemia, sepis, and other

shock states

Could it besinus

tachycardia?

Could it besinus

tachycardia?

YES

Is it narrow, perfectly regular,

and 150 or above?

Is it narrow, perfectly regular,

and 150 or above?

Paroxysmal supraventricular

tachycardia, unless sinustachycardia is possible

Paroxysmal supraventricular

tachycardia, unless sinustachycardia is possible

YES

Irregularly irregular, narrow

complex,probably

atrial fibrillationAlso consider

frequent ectopy,Variable Aflutter

and MAT

Irregularly irregular, narrow

complex,probably

atrial fibrillationAlso consider

frequent ectopy,Variable Aflutter

and MAT

Is it regular? Is it regular?NO

WIDE andPERFECTLY

regular,probably Vtach

WIDE and irregular,probably atrialfibrillation with

bundle branch block

WIDE andPERFECTLY

regular,probably Vtach

WIDE and irregular,probably atrialfibrillation with

bundle branch block

Is it wide?Is it wide? YES

Narrow OR wide,regular (usually),

with sawtoothbaseline

Narrow OR wide,regular (usually),

with sawtoothbaseline

Atrial flutter (fairly rare)

REMEMBER, the

block MAY bevariable in

flutter

Atrial flutter (fairly rare)

REMEMBER, the

block MAY bevariable in

flutter

YES

IMPORTANT:IMPORTANT:





Even More Important:Even More Important:

•When you can’t tell if a rhythm issinus tachycardia or PAT/PSVT,be wary of the more serious cause

•It may be difficult, or even impossible,to see any irregularity in very fast atrial fibrillation

•When you can’t tell if a rhythm issinus tachycardia or PAT/PSVT,be wary of the more serious cause

•It may be difficult, or even impossible,to see any irregularity in very fast atrial fibrillation

Case Studiesin

Tachycardia Evaluation

Case Studiesin

Tachycardia Evaluation

A 15 year old AA maleis found confused, sweaty, with

a respiratory rate of 36,a systolic pressure of 80, and

this EKG rhythm strip

A 15 year old AA maleis found confused, sweaty, with

a respiratory rate of 36,a systolic pressure of 80, and

this EKG rhythm strip

What is the “working impression”and what do you think

might be the cause of his problem?

What is the “working impression”and what do you think

might be the cause of his problem?

72 WF with a cardiac historypresents with palpitationsand shortness of breath

72 WF with a cardiac historypresents with palpitationsand shortness of breath

Her systolic is 130 andher lungs have rales

Her systolic is 130 andher lungs have rales

72 years old

220 – 72 = 148

72 years old

220 – 72 = 148

The Strip is at about 160What statement can you make?

The Strip is at about 160What statement can you make?

72 years old

220 – 72 = 148

72 years old

220 – 72 = 148

It HAS to be an arrhythmia!It can’t be sinus tach!

It HAS to be an arrhythmia!It can’t be sinus tach!

30 year old Sweet Suepresents with a systolic of 90and history of palpitationsplus abdominal pain today

30 year old Sweet Suepresents with a systolic of 90and history of palpitationsplus abdominal pain today

She ran out of her “heart pill”She ran out of her “heart pill”

30 year old femaleRate of 180

220 – 30 = 190


220 – 30 = 190

What statement can you make?What statement can you make?

Is it PSVT (hx of palpitations?)or Sinus Tach?

Which is more dangerous?

Is it PSVT (hx of palpitations?)or Sinus Tach?

Which is more dangerous?


220 – 30 = 190


220 – 30 = 190

60 year old Aunt Minniepresents with systolic of 90

and no cardiac history

60 year old Aunt Minniepresents with systolic of 90

and no cardiac history

She has been ill for two daysShe has been ill for two days

60 year old with rate of 158220 – 60 = 160


What statement can you make?What statement can you make?



Does she need Adenosine?Does she need Adenosine?

Speaking of AdenosineSpeaking of Adenosine

Summary ThoughtsAbout TachycardiaSummary ThoughtsAbout Tachycardia

•Don’t be a careless EKG reader•Your patients’ lives depend on it•Make YOUR medical director proud•Remember that you start with

the patient’s maximum possiblepulse rate (220 – age), eliminate sinus tachycardia

if it is too fast or doesn’t look right, and then figure it out from there

•Don’t be a careless EKG reader•Your patients’ lives depend on it•Make YOUR medical director proud•Remember that you start with

the patient’s maximum possiblepulse rate (220 – age), eliminate sinus tachycardia

if it is too fast or doesn’t look right, and then figure it out from there

Synthesis

Synthesis

So,Who’s

Foolin’ Who??

So,Who’s

Foolin’ Who??

The scope of practiceof these EMS professionals

continues to growwith passing years

The scope of practiceof these EMS professionals

continues to growwith passing years

EMS professionalsare primary members

of the emergency medical team.

EMS professionalsare primary members

of the emergency medical team.

Let us then apply our best efforts

in training and periodic retrainingwith the sharpened focus

of clarity and simplification,pooling our individual creativities

for the greater goodof those we serve.

Let us then apply our best efforts

in training and periodic retrainingwith the sharpened focus

of clarity and simplification,pooling our individual creativities

for the greater goodof those we serve.

This Talk may be found atThis Talk may be found at


[email protected]@doctorfowler.com

This Talk may be found atThis Talk may be found at


[email protected]@doctorfowler.com

. . . and Good Afternoon!. . . and Good Afternoon!

Questions or comments?

Questions or comments?

Documents

The Proper Interpretation of Tachycardias The Proper Interpretation of Tachycardias Breaking through the barriers Breaking through the barriers